Healthcare Provider Details

I. General information

NPI: 1417228032
Provider Name (Legal Business Name): DOUGLAS WILLIS CORRY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2012
Last Update Date: 03/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 S MAIN ST STE 101
CEDAR CITY UT
84720-3957
US

IV. Provider business mailing address

427 S MAIN ST STE 101
CEDAR CITY UT
84720-3957
US

V. Phone/Fax

Practice location:
  • Phone: 435-586-6526
  • Fax: 435-867-9230
Mailing address:
  • Phone: 435-586-6526
  • Fax: 435-867-9230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8705196
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number27130
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: