=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033202304
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM ABNEY CORLEY D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2006
-----------------------------------------------------
Last Update Date | 01/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 540 E ABRIENDO AVE SUITE D
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81004-2374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-545-8422
-----------------------------------------------------
Fax | 719-545-8422
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 540 E ABRIENDO AVE STE D
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81004-2377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-545-8422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 100881
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------