Provider Demographics
NPI:1821062696
Name:CORNISH, RICKY (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICKY
Middle Name:
Last Name:CORNISH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775
Mailing Address - Country:US
Mailing Address - Phone:417-256-4171
Mailing Address - Fax:417-256-9714
Practice Address - Street 1:1710 W BROADWAY
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775
Practice Address - Country:US
Practice Address - Phone:417-256-4171
Practice Address - Fax:417-256-9714
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0160541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice