Provider Demographics
NPI:1760008486
Name:ALFONSO, JOSE ANTONIO (DMD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:ANTONIO
Last Name:ALFONSO
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 1:775 N BROAD ST APT A504
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-2417
Mailing Address - Country:US
Mailing Address - Phone:786-614-8927
Mailing Address - Fax:
Practice Address - Street 1:775 N BROAD ST APT A504
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-2417
Practice Address - Country:US
Practice Address - Phone:786-614-8927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24955122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist