Provider Demographics
NPI:1619608023
Name:CORNELL, DAISY E
Entity Type:Individual
Prefix:
First Name:DAISY
Middle Name:E
Last Name:CORNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11043 WIDICUS RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IL
Mailing Address - Zip Code:62254-1157
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 TAMARACK LN
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-2993
Practice Address - Country:US
Practice Address - Phone:618-632-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019033724122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist