Provider Demographics
NPI:1427359991
Name:CORNETT, CASEY RENEA (RDH)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:RENEA
Last Name:CORNETT
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:WOLF POINT
Mailing Address - State:MT
Mailing Address - Zip Code:59201-6000
Mailing Address - Country:US
Mailing Address - Phone:406-653-1461
Mailing Address - Fax:406-653-3728
Practice Address - Street 1:550 6TH AVE N
Practice Address - Street 2:
Practice Address - City:WOLF POINT
Practice Address - State:MT
Practice Address - Zip Code:59201-6000
Practice Address - Country:US
Practice Address - Phone:406-653-1461
Practice Address - Fax:406-653-3728
Is Sole Proprietor?:No
Enumeration Date:2010-11-15
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4084124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT2210068Medicaid
KY4084OtherKY BOARD OF DENTISTRY