MEDICARE: DR. RICHARD E CORLEY D.D.S

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	1223G0001X	General Practice Dentistry	12483	FL

General Provider Information

NPI Number	:	1538241948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD E CORLEY D.D.S

Provider Business Mailing Address
First Line	:	14091 EMERALD COAST PKWY STE A
Second Line	:
City	:	DESTIN
State	:	FL
Zip	:	32541-3350
Country	:	US
Telephone Number	:	850-654-6969
Fax Number	:	850-654-1057

Provider Business Practice Location Address
First Line	:	14091 EMERALD COAST PKWY STE A
Second Line	:
City	:	DESTIN
State	:	FL
Zip	:	32541-3350
Country	:	US
Telephone Number	:	850-654-6969
Fax Number	:	850-654-1057

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	07/08/2007

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