Healthcare Provider Details

I. General information

NPI: 1366133365
Provider Name (Legal Business Name): JUSTIN TAYLOR CORNETT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2023
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 HIGHWAY 160 S
HINDMAN KY
41822
US

IV. Provider business mailing address

226 MEDICAL PLAZA LN
WHITESBURG KY
41858-7425
US

V. Phone/Fax

Practice location:
  • Phone: 606-633-4871
  • Fax:
Mailing address:
  • Phone: 606-633-4871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10948
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: