Provider Demographics
NPI:1841395829
Name:TOLLIVER, CORDELL W (DMD)
Entity Type:Individual
Prefix:DR
First Name:CORDELL
Middle Name:W
Last Name:TOLLIVER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:CORDELL
Other - Middle Name:W
Other - Last Name:TOLLIVER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:714 EXETER AVENUE
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-1461
Mailing Address - Country:US
Mailing Address - Phone:606-248-5302
Mailing Address - Fax:606-248-5302
Practice Address - Street 1:714 EXETER AVENUE
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-1461
Practice Address - Country:US
Practice Address - Phone:606-248-5302
Practice Address - Fax:606-248-5302
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4989122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0160739OtherBCBS TENN
VA0688009OtherDELTA DENTAL
KY60049897Medicaid