Provider Demographics
NPI:1275545162
Name:KORNACK, EDWARD GEORGE (DMD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:GEORGE
Last Name:KORNACK
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 1:1242 WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-4045
Mailing Address - Country:US
Mailing Address - Phone:781-762-3529
Mailing Address - Fax:781-762-4102
Practice Address - Street 1:1242 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-4045
Practice Address - Country:US
Practice Address - Phone:781-762-3529
Practice Address - Fax:781-762-4102
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA161771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice