Provider Demographics
NPI:1376126870
Name:ACOSTA, COREY (DDS)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:ACOSTA
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 1:717 S WHITE STATION RD STE 7
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-4538
Mailing Address - Country:US
Mailing Address - Phone:901-692-1404
Mailing Address - Fax:
Practice Address - Street 1:6611 KIRBY CENTER CV
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-4313
Practice Address - Country:US
Practice Address - Phone:901-363-8192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11562122300000X, 1223P0221X
TN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program