Provider Demographics
NPI:1447412705
Name:CORY, RANDALL STEVEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:STEVEN
Last Name:CORY
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 1:2400 WINONA AVE
Mailing Address - Street 2:UNIT H
Mailing Address - City:WINONA LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46590-2122
Mailing Address - Country:US
Mailing Address - Phone:574-269-9681
Mailing Address - Fax:
Practice Address - Street 1:801 N HUNTINGTON ST
Practice Address - Street 2:SUITE 11
Practice Address - City:SYRACUSE
Practice Address - State:IN
Practice Address - Zip Code:46567-1151
Practice Address - Country:US
Practice Address - Phone:574-269-9681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007293A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice