Healthcare Provider Details

I. General information

NPI: 1982965711
Provider Name (Legal Business Name): DEMION R CORNWALL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6620 CRAIN HWY SUITE 204
LAPLATA MD
20646
US

IV. Provider business mailing address

6620 CRAIN HWY #204
LAPLATA MD
20646
US

V. Phone/Fax

Practice location:
  • Phone: 301-870-3966
  • Fax: 301-753-1992
Mailing address:
  • Phone: 301-870-3966
  • Fax: 301-753-1992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13699
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: