Provider Demographics
NPI:1518050376
Name:CORONADO, EFRAIN
Entity Type:Individual
Prefix:DR
First Name:EFRAIN
Middle Name:
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 1:4280 LAVISTA RD STE C117
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5315
Mailing Address - Country:US
Mailing Address - Phone:678-688-4811
Mailing Address - Fax:404-855-4913
Practice Address - Street 1:4280 LAVISTA RD STE C117
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5315
Practice Address - Country:US
Practice Address - Phone:678-688-4811
Practice Address - Fax:404-855-4913
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN148391223G0001X
GADN0158881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice