Provider Demographics
NPI:1053516732
Name:CORREA, JACQUELINE (D M D)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:CORREA
Suffix:
Gender:F
Credentials:D M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12538 SW 120TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-9064
Mailing Address - Country:US
Mailing Address - Phone:305-646-6700
Mailing Address - Fax:
Practice Address - Street 1:12538 SW 120TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-9064
Practice Address - Country:US
Practice Address - Phone:305-646-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 176021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice