Provider Demographics
NPI:1023313160
Name:BLANKENSHIP, COREY COLEMAN (DDS)
Entity type:Individual
Prefix:DR
First Name:COREY
Middle Name:COLEMAN
Last Name:BLANKENSHIP
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 1:280 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CATHLAMET
Mailing Address - State:WA
Mailing Address - Zip Code:98612-9400
Mailing Address - Country:US
Mailing Address - Phone:360-795-3235
Mailing Address - Fax:360-544-0123
Practice Address - Street 1:280 2ND ST
Practice Address - Street 2:
Practice Address - City:CATHLAMET
Practice Address - State:WA
Practice Address - Zip Code:98612-9400
Practice Address - Country:US
Practice Address - Phone:360-795-3235
Practice Address - Fax:360-544-0123
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 601920581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
47-2165984OtherTAX EIN