Provider Demographics
NPI:1063538247
Name:CORCORAN, DAVID M (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:CORCORAN
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 1:6058 GARRETT LN
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5228
Mailing Address - Country:US
Mailing Address - Phone:815-398-5610
Mailing Address - Fax:815-398-8951
Practice Address - Street 1:6058 GARRETT LN
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5228
Practice Address - Country:US
Practice Address - Phone:815-398-5610
Practice Address - Fax:815-398-8951
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice