Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 22DI02506700 | NJ |
N | 1223E0200X | Endodontist | FC3508124 | NJ |
Y | 1223G0001X | General Practice | 9466 | SC |
Y | 213EG0000X | General Practice | 9466 | SC |
NPI | 1063760213 |
---|---|
Provider Name | Dr. Mauro Correa JR. |
First Address | Tacoma, WA 98431-0001 |
Second Address | Ft Jackson, SC 29207-6022 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/08/2012 |
Last Update Date | 23/09/2019 |