Healthcare Provider Details

I. General information

NPI: 1962814012
Provider Name (Legal Business Name): JOANNA CORNELIUS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2014
Last Update Date: 05/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5551 SUNSET BLVD
LEXINGTON SC
29072-9132
US

IV. Provider business mailing address

5551 SUNSET BLVD
LEXINGTON SC
29072-9132
US

V. Phone/Fax

Practice location:
  • Phone: 803-580-2009
  • Fax:
Mailing address:
  • Phone: 803-580-2009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: