Provider Demographics
NPI:1376702472
Name:CORNISH, ANNELIES SOPHIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANNELIES
Middle Name:SOPHIA
Last Name:CORNISH
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 1:2509 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-6145
Mailing Address - Country:US
Mailing Address - Phone:734-662-7874
Mailing Address - Fax:
Practice Address - Street 1:830 W CLARK RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-3403
Practice Address - Country:US
Practice Address - Phone:734-646-0419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019834122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist