Provider Demographics
NPI:1366679789
Name:CORNS, CARISSE (DDS)
Entity Type:Individual
Prefix:
First Name:CARISSE
Middle Name:
Last Name:CORNS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 CUMBERLAND XING
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2356
Mailing Address - Country:US
Mailing Address - Phone:219-286-6148
Mailing Address - Fax:219-286-6149
Practice Address - Street 1:1111 CUMBERLAND XING
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2356
Practice Address - Country:US
Practice Address - Phone:219-286-6148
Practice Address - Fax:219-286-6149
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-11
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA574611223P0221X
IN12011775A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry