Provider Demographics
NPI:1679015051
Name:ALFONSO, EMMANUEL (DDS)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
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 1:3611 SW 34TH ST APT 230
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-6574
Mailing Address - Country:US
Mailing Address - Phone:786-461-4840
Mailing Address - Fax:
Practice Address - Street 1:3611 SW 34TH ST APT 230
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-6574
Practice Address - Country:US
Practice Address - Phone:786-461-4840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16261223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics