Provider Demographics
NPI:1902367659
Name:KORNHABER, ADAM BRENT
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:BRENT
Last Name:KORNHABER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 W CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2335
Mailing Address - Country:US
Mailing Address - Phone:702-774-5175
Mailing Address - Fax:702-774-2812
Practice Address - Street 1:2656 N BUFFALO DR UNIT 1239
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-4812
Practice Address - Country:US
Practice Address - Phone:702-774-5175
Practice Address - Fax:702-774-2812
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLL-500-191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice