Provider Demographics
NPI:1134344666
Name:SONNENBERG, CORLIS L (DDS)
Entity type:Individual
Prefix:
First Name:CORLIS
Middle Name:L
Last Name:SONNENBERG
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 1:1317 EAST ST
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:TX
Mailing Address - Zip Code:76450-4230
Mailing Address - Country:US
Mailing Address - Phone:940-549-0350
Mailing Address - Fax:940-549-4261
Practice Address - Street 1:1317 EAST ST
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:TX
Practice Address - Zip Code:76450-4230
Practice Address - Country:US
Practice Address - Phone:940-549-0350
Practice Address - Fax:940-549-4261
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice