Provider Demographics
NPI:1679014567
Name:MENOU, COREY (DDS)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:
Last Name:MENOU
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 1:1830 E BROAD ST STE 104
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-9161
Mailing Address - Country:US
Mailing Address - Phone:817-473-7171
Mailing Address - Fax:817-473-2594
Practice Address - Street 1:1830 E BROAD ST STE 104
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-9161
Practice Address - Country:US
Practice Address - Phone:817-473-7171
Practice Address - Fax:817-473-2594
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-13
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX346811223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty