Provider Demographics
NPI:1720299712
Name:CAROTHERS, COREY CLIFFORD (DDS)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:CLIFFORD
Last Name:CAROTHERS
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:PO BOX 297
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78667-0297
Mailing Address - Country:US
Mailing Address - Phone:361-549-8331
Mailing Address - Fax:
Practice Address - Street 1:310 STAGECOACH TRL STE 700
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-5151
Practice Address - Country:US
Practice Address - Phone:512-396-4288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22947122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist