Provider Demographics
NPI:1609492297
Name:CARTER, COREY SHANNON (DMD)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:SHANNON
Last Name:CARTER
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 1:415 N LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-1223
Mailing Address - Country:US
Mailing Address - Phone:606-886-4260
Mailing Address - Fax:
Practice Address - Street 1:415 N LAKE DR
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-1223
Practice Address - Country:US
Practice Address - Phone:606-886-4260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY104731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice