Provider Demographics
NPI:1225048911
Name:ALFONSO, MARIO E (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:E
Last Name:ALFONSO
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 1:7085 SWINNEA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-6001
Mailing Address - Country:US
Mailing Address - Phone:662-349-3038
Mailing Address - Fax:662-349-3051
Practice Address - Street 1:7085 SWINNEA RD
Practice Address - Street 2:SUITE A
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-6001
Practice Address - Country:US
Practice Address - Phone:662-349-3038
Practice Address - Fax:662-349-3051
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS2062-841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice