MEDICARE: SCOTT WALLACE CORRY DDS

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	143160	UT

General Provider Information

NPI Number	:	1871618041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SCOTT WALLACE CORRY DDS

Provider Business Mailing Address
First Line	:	PO BOX 220
Second Line	:	88 E. STATE ST.
City	:	FARMINGTON
State	:	UT
Zip	:	84025-0220
Country	:	US
Telephone Number	:	801-451-2341
Fax Number	:

Provider Business Practice Location Address
First Line	:	88 E STATE ST
Second Line	:
City	:	FARMINGTON
State	:	UT
Zip	:	84025-2343
Country	:	US
Telephone Number	:	801-451-2341
Fax Number	:

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

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	07/08/2007

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