Provider Demographics
NPI:1770736563
Name:CERTOSIMO, ALFRED JOSEPH
Entity type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:JOSEPH
Last Name:CERTOSIMO
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:ALFRED
Other - Middle Name:JOSEPH
Other - Last Name:CERTOSIMO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:520 N 12TH ST
Mailing Address - Street 2:P.O. 980566
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-5064
Mailing Address - Country:US
Mailing Address - Phone:804-828-9190
Mailing Address - Fax:804-828-9358
Practice Address - Street 1:520 N 12TH ST
Practice Address - Street 2:P.O. 980566
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5064
Practice Address - Country:US
Practice Address - Phone:804-828-9190
Practice Address - Fax:804-828-9358
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-24
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010082641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA153654OtherUNITED CONCORDIA
VA453709OtherANTHEM
VA5894Medicaid