Provider Demographics
NPI:1750547782
Name:CORREA, JEROME ALAN (DDS)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:ALAN
Last Name:CORREA
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 1:62 ORLAND SQUARE DR
Mailing Address - Street 2:SUITE 304
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-6546
Mailing Address - Country:US
Mailing Address - Phone:708-349-1919
Mailing Address - Fax:708-349-1990
Practice Address - Street 1:62 ORLAND SQUARE DR
Practice Address - Street 2:SUITE 304
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-6546
Practice Address - Country:US
Practice Address - Phone:708-349-1919
Practice Address - Fax:708-349-1990
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190188431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice