Provider Demographics
NPI:1376647099
Name:CORLEY, PHILLIP WADE (DDS)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:WADE
Last Name:CORLEY
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 1:4200 W MEMORIAL RD
Mailing Address - Street 2:#507
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-9350
Mailing Address - Country:US
Mailing Address - Phone:405-751-0018
Mailing Address - Fax:405-751-0671
Practice Address - Street 1:4200 W MEMORIAL RD
Practice Address - Street 2:#507
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-9350
Practice Address - Country:US
Practice Address - Phone:405-751-0018
Practice Address - Fax:405-751-0671
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK48681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice