Provider Demographics
NPI:1972009744
Name:CORNELIUS DENTISTRY
Entity Type:Organization
Organization Name:CORNELIUS DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:B
Authorized Official - Last Name:HADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-655-2292
Mailing Address - Street 1:21025 CATAWBA AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-8569
Mailing Address - Country:US
Mailing Address - Phone:704-655-2292
Mailing Address - Fax:
Practice Address - Street 1:8301 MAGNOLIA ESTATES DR STE 4
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-8053
Practice Address - Country:US
Practice Address - Phone:704-655-2292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-02
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty