Provider Demographics
NPI:1336153501
Name:CORRELL, BRYAN LEWIS (DDS)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:LEWIS
Last Name:CORRELL
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 1:6821 N COUNTRY HOMES BLVD
Mailing Address - Street 2:SUITE 202A
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-4372
Mailing Address - Country:US
Mailing Address - Phone:509-325-2188
Mailing Address - Fax:509-327-8562
Practice Address - Street 1:6821 N COUNTRY HOMES BLVD
Practice Address - Street 2:SUITE 202A
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-4372
Practice Address - Country:US
Practice Address - Phone:509-325-2188
Practice Address - Fax:509-327-8562
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE74921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice