Healthcare Provider Details

I. General information

NPI: 1902094592
Provider Name (Legal Business Name): DOUGLAS JOE CORNISH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 01/04/2021
Certification Date: 12/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E HWY 175 STE 700
CRANDALL TX
75114
US

IV. Provider business mailing address

1101 E HWY 175 STE 700
CRANDALL TX
75114
US

V. Phone/Fax

Practice location:
  • Phone: 972-427-0333
  • Fax: 972-472-3908
Mailing address:
  • Phone: 972-427-0333
  • Fax: 972-472-3908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number27829
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: