MEDICARE: CORPODIAN DENTAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	62505	CA

General Provider Information

NPI Number	:	1447675368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORPODIAN DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	120 TUSTIN AVE
Second Line	:	C252
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92663-4729
Country	:	US
Telephone Number	:	702-370-1644
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 TUSTIN AVE
Second Line	:	C252
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92663-4729
Country	:	US
Telephone Number	:	702-370-1644
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DOCTOR/PRESIDENT
Name	:	DR. COREY CORPODIAN
Credential	:	DDS
Telephone Number	:	702-370-1644

Provider Enumeration Date	:	02/28/2014
Last Update Date	:	05/22/2014

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Directions to “CORPODIAN DENTAL CORPORATION ” Practice Location

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