Provider Demographics
NPI:1124759196
Name:BENTLEY, COREY AUSTIN (DMD)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:AUSTIN
Last Name:BENTLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 MORTON BLVD
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-9469
Mailing Address - Country:US
Mailing Address - Phone:606-439-3557
Mailing Address - Fax:606-439-1422
Practice Address - Street 1:750 MORTON BLVD
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9469
Practice Address - Country:US
Practice Address - Phone:606-439-3557
Practice Address - Fax:606-439-1422
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10814122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist