MEDICARE: HOLDEN CORRELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1053887182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLDEN CORRELL

Provider Business Mailing Address
First Line	:	4102 W 6TH ST STE B
Second Line	:
City	:	LAWRENCE
State	:	KS
Zip	:	66049-4626
Country	:	US
Telephone Number	:	785-969-6531
Fax Number	:

Provider Business Practice Location Address
First Line	:	4102 W 6TH ST STE B
Second Line	:
City	:	LAWRENCE
State	:	KS
Zip	:	66049-4626
Country	:	US
Telephone Number	:	785-969-6531
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. HOLDEN LEE CORRELL
Credential	:	DDS
Telephone Number	:	785-969-6531

Provider Enumeration Date	:	10/16/2018
Last Update Date	:	10/25/2018

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