Provider Demographics
NPI:1396397386
Name:DANIEL, CORNELIUS HOMER (DMD)
Entity Type:Individual
Prefix:DR
First Name:CORNELIUS
Middle Name:HOMER
Last Name:DANIEL
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 1:3202 HALEYS WAY SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-6445
Mailing Address - Country:US
Mailing Address - Phone:404-216-0023
Mailing Address - Fax:
Practice Address - Street 1:2239 HIGHWAY 20 SE STE H
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2087
Practice Address - Country:US
Practice Address - Phone:770-921-3565
Practice Address - Fax:770-921-3534
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0159211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice