Provider Demographics
NPI:1891815585
Name:CORREALE, MICHAEL G (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:G
Last Name:CORREALE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:ST FRANCOIS PLAZA
Other - Middle Name:DENTAL
Other - Last Name:CENTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DBA
Mailing Address - Street 1:111 SAINT FRANCOIS PLZ
Mailing Address - Street 2:
Mailing Address - City:LEADINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63601-4454
Mailing Address - Country:US
Mailing Address - Phone:573-431-5155
Mailing Address - Fax:573-421-0576
Practice Address - Street 1:111 SAINT FRANCOIS PLZ
Practice Address - Street 2:
Practice Address - City:LEADINGTON
Practice Address - State:MO
Practice Address - Zip Code:63601-4454
Practice Address - Country:US
Practice Address - Phone:573-431-5155
Practice Address - Fax:573-421-0576
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO13428122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist