Provider Demographics
NPI:1558494559
Name:CORDELL, KITRINA G (DDS MS)
Entity Type:Individual
Prefix:
First Name:KITRINA
Middle Name:G
Last Name:CORDELL
Suffix:
Gender:F
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-2714
Mailing Address - Country:US
Mailing Address - Phone:504-941-8449
Mailing Address - Fax:504-941-8336
Practice Address - Street 1:1100 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-2714
Practice Address - Country:US
Practice Address - Phone:504-941-8449
Practice Address - Fax:504-941-8336
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901018465122300000X, 1223P0106X
LAP-1231223P0106X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1958112200OtherBCBS OF MI MED SURGICAL
MID184650OtherBCBS OF MI DENTAL
MI4874070Medicaid
MI4500641Medicaid
MID184650OtherBCBS OF MI DENTAL
MIN65440016Medicare PIN
MI4874070Medicaid