Provider Demographics
NPI:1750481719
Name:KORNEGAY, JAMES M (DDS,MAGD,PA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:KORNEGAY
Suffix:
Gender:M
Credentials:DDS,MAGD,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 390189
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32739-0189
Mailing Address - Country:US
Mailing Address - Phone:386-789-7990
Mailing Address - Fax:386-789-4503
Practice Address - Street 1:1617 CATALINA BLVD
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-9699
Practice Address - Country:US
Practice Address - Phone:386-789-7990
Practice Address - Fax:386-789-4503
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL111031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice