Provider Demographics
NPI:1265050892
Name:CORNWELL, NICHOLAS (DMD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:CORNWELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97604 FRANKLIN RDG
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-8357
Mailing Address - Country:US
Mailing Address - Phone:908-963-1885
Mailing Address - Fax:
Practice Address - Street 1:6570 SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27023-8651
Practice Address - Country:US
Practice Address - Phone:336-945-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC118861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice