Provider Demographics
NPI:1073245551
Name:CALLAHAN, CORY
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:CALLAHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 WILLOW SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:SYKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21784-5601
Mailing Address - Country:US
Mailing Address - Phone:443-844-6212
Mailing Address - Fax:
Practice Address - Street 1:5126 DORSEY HALL DR
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7887
Practice Address - Country:US
Practice Address - Phone:410-740-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD175321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice