Healthcare Provider Details

I. General information

NPI: 1023148244
Provider Name (Legal Business Name): JANINE K CORNELIUS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3317 W MULLEN AVE
TAMPA FL
33609-4657
US

IV. Provider business mailing address

3317 W MULLEN AVE
TAMPA FL
33609-4657
US

V. Phone/Fax

Practice location:
  • Phone: 813-382-4630
  • Fax:
Mailing address:
  • Phone: 813-382-4630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number12140
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN12140
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: