Provider Demographics
NPI:1376439299
Name:CORLEY, MEGUMI KONDO (DMD)
Entity type:Individual
Prefix:
First Name:MEGUMI
Middle Name:KONDO
Last Name:CORLEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S 15TH ST APT 2305
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-2608
Mailing Address - Country:US
Mailing Address - Phone:908-692-0825
Mailing Address - Fax:
Practice Address - Street 1:240 GEIGER RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-1008
Practice Address - Country:US
Practice Address - Phone:215-677-0380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS045180122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist