Provider Demographics
NPI:1063760213
Name:CORREA, MAURO JR (DMD)
Entity type:Individual
Prefix:DR
First Name:MAURO
Middle Name:
Last Name:CORREA
Suffix:JR
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 1:9900 LINCOLN ST FL 2
Mailing Address - Street 2:USA DENTAL ACTIVITY
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:253-968-4029
Mailing Address - Fax:
Practice Address - Street 1:4323 HILL STREET
Practice Address - Street 2:USA DENTAL HEALTH ACTIVITY
Practice Address - City:FT JACKSON
Practice Address - State:SC
Practice Address - Zip Code:29207-6022
Practice Address - Country:US
Practice Address - Phone:803-751-6209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-20
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02506700122300000X
NJFC35081241223E0200X
SC94661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No1223E0200XDental ProvidersDentistEndodontics