Provider Demographics
NPI:1417066093
Name:KORNEGAY, KIM PIERSON (DMD)
Entity Type:Individual
Prefix:MR
First Name:KIM
Middle Name:PIERSON
Last Name:KORNEGAY
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 1:711 KORNEGAY DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36066-7715
Mailing Address - Country:US
Mailing Address - Phone:334-285-7111
Mailing Address - Fax:334-285-3310
Practice Address - Street 1:711 KORNEGAY DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-7715
Practice Address - Country:US
Practice Address - Phone:334-285-7111
Practice Address - Fax:334-285-3310
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALCS38631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL776896OtherUNITED CONCORDIA
AL90076OtherBLUE CROSS BLUE SHIELD