Provider Demographics
NPI:1689308678
Name:CORNEJO ZAVALA, SIXTO RAFAEL (DMD)
Entity Type:Individual
Prefix:
First Name:SIXTO
Middle Name:RAFAEL
Last Name:CORNEJO ZAVALA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 TECHNOLOGY PARK STE 101
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-7122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4732 S KIRKMAN RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-3643
Practice Address - Country:US
Practice Address - Phone:407-292-7373
Practice Address - Fax:407-992-8858
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN272361223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics