Provider Demographics
NPI:1144304809
Name:RIDGELL, CORNAL (DMD)
Entity type:Individual
Prefix:
First Name:CORNAL
Middle Name:
Last Name:RIDGELL
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 1:21700 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4906
Mailing Address - Country:US
Mailing Address - Phone:248-423-9393
Mailing Address - Fax:248-423-7893
Practice Address - Street 1:25296 EVERGREEN RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-1760
Practice Address - Country:US
Practice Address - Phone:248-423-9393
Practice Address - Fax:248-423-7893
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010157751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice