MEDICARE: CORONA DENTAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1376978338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORONA DENTAL LLC

Provider Business Mailing Address
First Line	:	55 E TALLAHASSEE DR
Second Line	:
City	:	CORONA DE TUCSON
State	:	AZ
Zip	:	85641-2310
Country	:	US
Telephone Number	:	520-762-0123
Fax Number	:	520-762-1100

Provider Business Practice Location Address
First Line	:	55 E TALLAHASSEE DR
Second Line	:
City	:	CORONA DE TUCSON
State	:	AZ
Zip	:	85641-2310
Country	:	US
Telephone Number	:	520-762-0123
Fax Number	:	520-762-1100

Authorized Official
Title or Position	:	OWNER/DOCTOR
Name	:	JARED HAWS
Credential	:	D.D.S
Telephone Number	:	520-762-0123

Provider Enumeration Date	:	09/10/2013
Last Update Date	:	09/10/2013

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Directions to “CORONA DENTAL LLC ” Practice Location

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