MEDICARE: DR. CORRELL A COUCH 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	26747	CA

General Provider Information

NPI Number	:	1851412639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CORRELL A COUCH D.D.S.

Provider Business Mailing Address
First Line	:	1600 COLORADO AVE # 1
Second Line	:
City	:	TURLOCK
State	:	CA
Zip	:	95382-2713
Country	:	US
Telephone Number	:	209-634-9069
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 COLORADO AVE # 1
Second Line	:
City	:	TURLOCK
State	:	CA
Zip	:	95382-2713
Country	:	US
Telephone Number	:	209-634-9069
Fax Number	:

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

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	07/08/2007

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