Provider Demographics
NPI:1518169747
Name:CORSA, KEJEN PI (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEJEN
Middle Name:PI
Last Name:CORSA
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 1:432 YORK DR
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-1425
Mailing Address - Country:US
Mailing Address - Phone:707-745-6982
Mailing Address - Fax:
Practice Address - Street 1:1545 N TEXAS ST
Practice Address - Street 2:SUITE 311
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-5623
Practice Address - Country:US
Practice Address - Phone:707-422-2410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice