Provider Demographics
NPI:1508856196
Name:CORDER, CHRISTOPHER SCOTT (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:SCOTT
Last Name:CORDER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W STEPHEN FOSTER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-1457
Mailing Address - Country:US
Mailing Address - Phone:502-348-5800
Mailing Address - Fax:502-348-9990
Practice Address - Street 1:120 W STEPHEN FOSTER AVE STE 104
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-1457
Practice Address - Country:US
Practice Address - Phone:502-348-5800
Practice Address - Fax:502-722-2116
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY76451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY10964OtherDORAL DENTAL PASSPORT, KY
KY60000395Medicaid