=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578131066
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CORY MCLEARY DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2021
-----------------------------------------------------
Last Update Date | 06/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 410 S PINE ST
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35630-6131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-766-3811
-----------------------------------------------------
Fax | 256-766-6567
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 410 S PINE ST
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35630-6131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-766-3811
-----------------------------------------------------
Fax | 256-766-6567
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D-0006894-C1
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------