Provider Demographics
NPI:1548433329
Name:KIM P. KORNEGAY, DMD
Entity type:Organization
Organization Name:KIM P. KORNEGAY, DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:PIERSON
Authorized Official - Last Name:KORNEGAY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:334-285-7111
Mailing Address - Street 1:711 KORNEGAY DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36066-7715
Mailing Address - Country:US
Mailing Address - Phone:334-285-7111
Mailing Address - Fax:334-285-3310
Practice Address - Street 1:711 KORNEGAY DR
Practice Address - Street 2:SUITE A
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-7715
Practice Address - Country:US
Practice Address - Phone:334-285-7111
Practice Address - Fax:334-285-3310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALCS38631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL776896OtherUNITED CONCORIA
AL90076OtherBLUECROSSBLUESHIELD OF AL