Healthcare Provider Details

I. General information

NPI: 1881696458
Provider Name (Legal Business Name): COREY MARK STANLEY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 MDG/SGIC 101 BODIN CIR
TRAVIS AFB CA
94535
US

IV. Provider business mailing address

101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-7008
  • Fax:
Mailing address:
  • Phone: 707-423-7008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD-4796-PE
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE7342
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: