Provider Demographics
NPI:1205914470
Name:PHILIP P CORNELIUSON DDS INC
Entity type:Organization
Organization Name:PHILIP P CORNELIUSON DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:P
Authorized Official - Last Name:CORNELIUSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:559-261-0185
Mailing Address - Street 1:5475 N FRESNO ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710
Mailing Address - Country:US
Mailing Address - Phone:559-261-0185
Mailing Address - Fax:559-261-2386
Practice Address - Street 1:5475 N FRESNO ST
Practice Address - Street 2:SUITE 103
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710
Practice Address - Country:US
Practice Address - Phone:559-261-0185
Practice Address - Fax:559-261-2386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty