Provider Demographics
NPI:1447268651
Name:CORNIELSEN, ERNST A (DDS)
Entity type:Individual
Prefix:
First Name:ERNST
Middle Name:A
Last Name:CORNIELSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W3627 WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-3568
Mailing Address - Country:US
Mailing Address - Phone:262-248-2868
Mailing Address - Fax:262-248-7274
Practice Address - Street 1:312 CENTER ST
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-1904
Practice Address - Country:US
Practice Address - Phone:262-248-2868
Practice Address - Fax:262-248-7274
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1732-G1223S0112X
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206370Medicare ID - Type Unspecified
WIT35306Medicare UPIN
WI76484Medicare ID - Type Unspecified