Provider Demographics
NPI:1528155405
Name:WARREN, ALFRED B (DDS)
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:B
Last Name:WARREN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1515
Mailing Address - Street 2:
Mailing Address - City:PORT SALERNO
Mailing Address - State:FL
Mailing Address - Zip Code:34992-1515
Mailing Address - Country:US
Mailing Address - Phone:772-285-0791
Mailing Address - Fax:
Practice Address - Street 1:3337 SE SALERNO RD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-6736
Practice Address - Country:US
Practice Address - Phone:772-285-0791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN50181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL760706979OtherTAX I.D.
FL000658300Medicaid