Provider Demographics
NPI:1346322716
Name:CORK, DONALD B JR (DDS)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:B
Last Name:CORK
Suffix:JR
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 1:5185 HEBRON DR
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-8157
Mailing Address - Country:US
Mailing Address - Phone:712-253-8417
Mailing Address - Fax:
Practice Address - Street 1:7500 LAKE ANDREW DR UNIT 102
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8763
Practice Address - Country:US
Practice Address - Phone:321-622-3033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN265861223G0001X
SDM8471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD46044478600Medicaid
NE46044478613Medicaid
IA0989517Medicaid