Provider Demographics
NPI:1063797009
Name:CORONA DENTAL OFFICE, PC
Entity type:Organization
Organization Name:CORONA DENTAL OFFICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WASCAR
Authorized Official - Middle Name:ALEXI
Authorized Official - Last Name:RAMIREZ
Authorized Official - Suffix:I
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-760-3417
Mailing Address - Street 1:10807 CORONA AVE
Mailing Address - Street 2:2 FLOOR
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-3941
Mailing Address - Country:US
Mailing Address - Phone:718-760-3417
Mailing Address - Fax:718-760-3417
Practice Address - Street 1:10807 CORONA AVE
Practice Address - Street 2:2 FLOOR
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-3941
Practice Address - Country:US
Practice Address - Phone:718-760-3417
Practice Address - Fax:718-760-3417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04848611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty