Provider Demographics
NPI:1063738730
Name:CORREA, LEOPOLDO PEDRO
Entity type:Individual
Prefix:DR
First Name:LEOPOLDO
Middle Name:PEDRO
Last Name:CORREA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 KNEELAND ST
Mailing Address - Street 2:SUITE# 601
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1527
Mailing Address - Country:US
Mailing Address - Phone:617-636-6817
Mailing Address - Fax:617-636-3831
Practice Address - Street 1:1 KNEELAND ST
Practice Address - Street 2:SUITE# 601
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1527
Practice Address - Country:US
Practice Address - Phone:617-636-6817
Practice Address - Fax:617-636-3831
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-20
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADF120181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice