Provider Demographics
NPI:1841338175
Name:CORNELIUS, CLIFFORD W (DDS)
Entity type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:W
Last Name:CORNELIUS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 N SWAN ROAD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712
Mailing Address - Country:US
Mailing Address - Phone:520-745-6531
Mailing Address - Fax:520-790-3817
Practice Address - Street 1:3150 N SWAN ROAD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712
Practice Address - Country:US
Practice Address - Phone:520-745-6531
Practice Address - Fax:520-790-3817
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5116204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ510976Medicaid
AZAZ5116OtherDELTA
AZAZ0472930OtherBLUE CROSS
AZAZ0472930OtherBLUE CROSS
AZ510976Medicaid