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General NPI Number Information
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NPI Number | 1144304809
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Entity Type | Individual
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Provider Name | CORNAL RIDGELL D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 10/25/2006
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Last Update Date | 10/10/2023
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Provider Practice Location Address
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Address Line | 25296 EVERGREEN RD
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City | SOUTHFIELD
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State | MI
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Zip | 48075-1760
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Country | US
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Telephone | 248-423-9393
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Fax | 248-423-7893
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Provider Business Mailing Address
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Address Line | 21700 NORTHWESTERN HWY SUITE 180
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City | SOUTHFIELD
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State | MI
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Zip | 48075-4906
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Country | US
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Telephone | 248-423-9393
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Fax | 248-423-7893
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2901015775
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License Number State | MI
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