=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972815835
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALI CORREA DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2010
-----------------------------------------------------
Last Update Date | 03/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 229 CROCKET BLVD
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-435-3064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8908 ALBERT STEWART LN
-----------------------------------------------------
City | SILVER SPRING
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20910-1901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN20957
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------