1639607195 NPI number — MRS. GLORIA MAITE SERRANO CORONADO DDS

Table of content: MRS. GLORIA MAITE SERRANO CORONADO DDS (NPI 1639607195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639607195 NPI number — MRS. GLORIA MAITE SERRANO CORONADO DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SERRANO CORONADO
Provider First Name:
GLORIA
Provider Middle Name:
MAITE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CORONADO MENDEZ
Provider Other First Name:
GLORIA
Provider Other Middle Name:
MAITE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639607195
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1537 LECONTE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37803-5613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-364-5648
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
824 W LAMAR ALEXANDER PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARYVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37801-4578
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-379-7004
Provider Business Practice Location Address Fax Number:
865-379-7040
Provider Enumeration Date:
05/30/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 10580 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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