Provider Demographics
NPI:1124196266
Name:CORONADO, HUGO RENE
Entity Type:Individual
Prefix:
First Name:HUGO
Middle Name:RENE
Last Name:CORONADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6741 N WILLOW AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5955
Mailing Address - Country:US
Mailing Address - Phone:559-385-7403
Mailing Address - Fax:559-439-6495
Practice Address - Street 1:6741 N WILLOW AVE STE 104
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5955
Practice Address - Country:US
Practice Address - Phone:559-385-7403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54243122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist