Provider Demographics
NPI:1871638130
Name:CORDER, PHIL M (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHIL
Middle Name:M
Last Name:CORDER
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 1:2204 POINT DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-2870
Mailing Address - Country:US
Mailing Address - Phone:318-387-6905
Mailing Address - Fax:
Practice Address - Street 1:117 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5331
Practice Address - Country:US
Practice Address - Phone:318-387-8504
Practice Address - Fax:318-387-4757
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA23971223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1823970Medicaid