Provider Demographics
NPI:1689017261
Name:FLAGG, CORISSA JULIE (RDH)
Entity type:Individual
Prefix:
First Name:CORISSA
Middle Name:JULIE
Last Name:FLAGG
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11321 IBIS ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3750
Mailing Address - Country:US
Mailing Address - Phone:763-238-2136
Mailing Address - Fax:
Practice Address - Street 1:1700 HIGHWAY 36 W
Practice Address - Street 2:STE 860
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55113-4034
Practice Address - Country:US
Practice Address - Phone:651-778-9911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH8180124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist