=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437451481
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RONALD CORLEY, DDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2010
-----------------------------------------------------
Last Update Date | 11/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 614 ANDREW AVE
-----------------------------------------------------
City | LA PORTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46350-4677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-326-7530
-----------------------------------------------------
Fax | 219-326-7531
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 614 ANDREW AVE
-----------------------------------------------------
City | LA PORTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46350-4677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-326-7530
-----------------------------------------------------
Fax | 219-326-7531
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | DR. RONALD K CORLEY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 219-326-7530
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------