Provider Demographics
NPI:1174501696
Name:CORSON, MITCHELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:
Last Name:CORSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9733 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-3201
Mailing Address - Country:US
Mailing Address - Phone:215-813-9292
Mailing Address - Fax:609-350-7022
Practice Address - Street 1:9990 VERREE RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-1322
Practice Address - Country:US
Practice Address - Phone:215-813-9292
Practice Address - Fax:609-350-7022
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS14219L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist