Provider Demographics
NPI:1205046281
Name:PRYOR, CORNELIUS MAURICE III (DDS)
Entity type:Individual
Prefix:DR
First Name:CORNELIUS
Middle Name:MAURICE
Last Name:PRYOR
Suffix:III
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 1:4139 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-4001
Mailing Address - Country:US
Mailing Address - Phone:323-839-8238
Mailing Address - Fax:702-307-1305
Practice Address - Street 1:3824 COOL MEADOWS DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-6872
Practice Address - Country:US
Practice Address - Phone:323-839-8238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7957122300000X
CA35538122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB35538-01Medicare ID - Type UnspecifiedMEDICAL #