Provider Demographics
NPI:1639607195
Name:SERRANO CORONADO, GLORIA MAITE (DDS)
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:MAITE
Last Name:SERRANO CORONADO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MISS
Other - First Name:GLORIA
Other - Middle Name:MAITE
Other - Last Name:CORONADO MENDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1537 LECONTE DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-5613
Mailing Address - Country:US
Mailing Address - Phone:770-364-5648
Mailing Address - Fax:
Practice Address - Street 1:824 W LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-4578
Practice Address - Country:US
Practice Address - Phone:865-379-7004
Practice Address - Fax:865-379-7040
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN10580122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program