Healthcare Provider Details

I. General information

NPI: 1720103468
Provider Name (Legal Business Name): RICHARD WADE CORLEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E CHOCTAW AVE SUITE 108
MCALESTER OK
74501-5068
US

IV. Provider business mailing address

215 E CHOCTAW AVE SUITE 108
MCALESTER OK
74501-5068
US

V. Phone/Fax

Practice location:
  • Phone: 918-423-2628
  • Fax:
Mailing address:
  • Phone: 918-423-2628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2923
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: