Provider Demographics
NPI:1477107464
Name:CONSUEGRA, KATIA (DMD)
Entity Type:Individual
Prefix:
First Name:KATIA
Middle Name:
Last Name:CONSUEGRA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27174 ELAINE DR
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-6058
Mailing Address - Country:US
Mailing Address - Phone:239-273-5685
Mailing Address - Fax:
Practice Address - Street 1:26831 S TAMIAMI TRL UNIT 48
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-7828
Practice Address - Country:US
Practice Address - Phone:239-948-3200
Practice Address - Fax:239-948-3098
Is Sole Proprietor?:No
Enumeration Date:2019-07-28
Last Update Date:2019-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL244741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice