Provider Demographics
NPI:1063626539
Name:CORREA, GEORGE MARK (DMD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:MARK
Last Name:CORREA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 MARIN ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-4261
Mailing Address - Country:US
Mailing Address - Phone:805-374-8484
Mailing Address - Fax:805-374-9819
Practice Address - Street 1:509 MARIN ST
Practice Address - Street 2:SUITE 220
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-4261
Practice Address - Country:US
Practice Address - Phone:805-374-8484
Practice Address - Fax:805-374-9819
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30542122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist