Provider Demographics
NPI:1356850754
Name:STILL, KOREY B (DDS)
Entity Type:Individual
Prefix:DR
First Name:KOREY
Middle Name:B
Last Name:STILL
Suffix:
Gender:F
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:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:SAN FIDEL
Mailing Address - State:NM
Mailing Address - Zip Code:87049-0130
Mailing Address - Country:US
Mailing Address - Phone:505-552-5300
Mailing Address - Fax:
Practice Address - Street 1:80 B VETERANS BLVD.
Practice Address - Street 2:
Practice Address - City:ACOMA
Practice Address - State:NM
Practice Address - Zip Code:87034
Practice Address - Country:US
Practice Address - Phone:505-552-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017029561122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH3451Medicaid