Healthcare Provider Details

I. General information

NPI: 1942932108
Provider Name (Legal Business Name): CORY WARNER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 S AMMON RD
AMMON ID
83406-6860
US

IV. Provider business mailing address

432 N 3900 E
RIGBY ID
83442-5138
US

V. Phone/Fax

Practice location:
  • Phone: 208-528-7665
  • Fax:
Mailing address:
  • Phone: 208-716-0375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD011479
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD5497
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: