Provider Demographics
NPI:1619171170
Name:CORDRAY, TRISTAN (DMD)
Entity type:Individual
Prefix:DR
First Name:TRISTAN
Middle Name:
Last Name:CORDRAY
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 1:56 COLLETON DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7301
Mailing Address - Country:US
Mailing Address - Phone:843-209-7334
Mailing Address - Fax:
Practice Address - Street 1:1142 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT STEPHEN
Practice Address - State:SC
Practice Address - Zip Code:29479-3996
Practice Address - Country:US
Practice Address - Phone:843-567-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4328122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist