Basic Information
| Provider Information | |||||||||
| NPI: | 1063760213 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORREA | ||||||||
| FirstName: | MAURO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9900 LINCOLN ST FL 2 | ||||||||
| Address2: | USA DENTAL ACTIVITY | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539684029 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4323 HILL STREET | ||||||||
| Address2: | USA DENTAL HEALTH ACTIVITY | ||||||||
| City: | FT JACKSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292076022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037516209 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2012 | ||||||||
| LastUpdateDate: | 09/23/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 22DI02506700 | NJ | N | Dental Providers | Dentist | 1223E0200X | FC3508124 | NJ | N | Dental Providers | Dentist | Endodontics | 1223G0001X | 9466 | SC | Y | Dental Providers | Dentist | General Practice |
No ID Information.