Provider Demographics
NPI:1851554521
Name:CORCORAN, GERALD ROGER (DDS)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:ROGER
Last Name:CORCORAN
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 1:21 NORTH MAIN STREET
Mailing Address - Street 2:SUITE 103
Mailing Address - City:DE FOREST
Mailing Address - State:WI
Mailing Address - Zip Code:53532
Mailing Address - Country:US
Mailing Address - Phone:608-846-3948
Mailing Address - Fax:608-846-7526
Practice Address - Street 1:210 N MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:DE FOREST
Practice Address - State:WI
Practice Address - Zip Code:53532-1163
Practice Address - Country:US
Practice Address - Phone:608-846-3948
Practice Address - Fax:608-846-7526
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2412122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist