Basic Information
| Provider Information | |||||||||
| NPI: | 1154727394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRINGTON | ||||||||
| FirstName: | COREY | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 CALIFORNIA STREET | ||||||||
| Address2: | PO BOX 577 | ||||||||
| City: | CARTERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629180577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189858221 | ||||||||
| FaxNumber: | 6189854635 | ||||||||
| Practice Location | |||||||||
| Address1: | 402 SOUTH LEWIS LANE | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185199901 | ||||||||
| FaxNumber: | 6185199375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2014 | ||||||||
| LastUpdateDate: | 02/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 019.030075 | IL | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 019030075 | 05 | IL | MEDICAID |