Provider Demographics
NPI:1417002973
Name:CORNELIUS, BRYANT (DDS, MBA, MPH)
Entity Type:Individual
Prefix:DR
First Name:BRYANT
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:M
Credentials:DDS, MBA, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 TOLLGATE RD
Mailing Address - Street 2:
Mailing Address - City:ZELIENOPLE
Mailing Address - State:PA
Mailing Address - Zip Code:16063-3030
Mailing Address - Country:US
Mailing Address - Phone:970-260-8629
Mailing Address - Fax:
Practice Address - Street 1:260 TOLLGATE RD
Practice Address - Street 2:
Practice Address - City:ZELIENOPLE
Practice Address - State:PA
Practice Address - Zip Code:16063-3030
Practice Address - Country:US
Practice Address - Phone:970-260-8629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0396001223D0004X
OH300249981223S0112X
OH30.0249981223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDentist Anesthesiologist
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery