Provider Demographics
NPI:1720103468
Name:CORLEY, RICHARD WADE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WADE
Last Name:CORLEY
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 1:215 E CHOCTAW AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-5068
Mailing Address - Country:US
Mailing Address - Phone:918-423-2628
Mailing Address - Fax:
Practice Address - Street 1:215 E CHOCTAW AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5068
Practice Address - Country:US
Practice Address - Phone:918-423-2628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29231223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics