Provider Demographics
NPI:1346322716
Name:CORK, DONALD B JR (DDS)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:B
Last Name:CORK
Suffix:JR
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 1:904 WYNSTONE RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:SD
Mailing Address - Zip Code:57038-6868
Mailing Address - Country:US
Mailing Address - Phone:605-422-1789
Mailing Address - Fax:605-422-1789
Practice Address - Street 1:101 MERRILL AVE
Practice Address - Street 2:
Practice Address - City:NORTH SIOUX CITY
Practice Address - State:SD
Practice Address - Zip Code:57049
Practice Address - Country:US
Practice Address - Phone:605-232-8802
Practice Address - Fax:605-232-0973
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM8471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE46044478613Medicaid
SD46044478600Medicaid
IA0989517Medicaid