Provider Demographics
NPI:1366133365
Name:CORNETT, JUSTIN TAYLOR (DMD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:TAYLOR
Last Name:CORNETT
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 1:226 MEDICAL PLAZA LN
Mailing Address - Street 2:
Mailing Address - City:WHITESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41858-7425
Mailing Address - Country:US
Mailing Address - Phone:606-633-4871
Mailing Address - Fax:
Practice Address - Street 1:1970 HIGHWAY 160 S
Practice Address - Street 2:
Practice Address - City:HINDMAN
Practice Address - State:KY
Practice Address - Zip Code:41822
Practice Address - Country:US
Practice Address - Phone:606-633-4871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10948122300000X, 1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Yes122300000XDental ProvidersDentist