Provider Demographics
NPI:1992831341
Name:CORRAL, ANTHONY R (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:R
Last Name:CORRAL
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 1:7768 OZARK DR UNIT 200
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-5839
Mailing Address - Country:US
Mailing Address - Phone:904-442-6000
Mailing Address - Fax:
Practice Address - Street 1:9776 SAN JOSE BLVD STE 7
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-5464
Practice Address - Country:US
Practice Address - Phone:904-268-6752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN170631223G0001X, 1223G0001X
FLDN144721223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty