Provider Demographics
NPI:1740551167
Name:CORNILS FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:CORNILS FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:CHASE
Authorized Official - Last Name:CORNILS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-914-5089
Mailing Address - Street 1:2016 W MCGALLIARD RD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-2148
Mailing Address - Country:US
Mailing Address - Phone:765-284-7242
Mailing Address - Fax:
Practice Address - Street 1:2016 W MCGALLIARD RD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-2148
Practice Address - Country:US
Practice Address - Phone:765-284-7242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011436A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental