Provider Demographics
NPI:1891713863
Name:BRENT CORNELIUS DDS PA
Entity Type:Organization
Organization Name:BRENT CORNELIUS DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNELIUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-431-4200
Mailing Address - Street 1:123 KELLER PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-2255
Mailing Address - Country:US
Mailing Address - Phone:817-431-4200
Mailing Address - Fax:
Practice Address - Street 1:123 KELLER PKWY STE 100
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-2255
Practice Address - Country:US
Practice Address - Phone:817-431-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX193341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty