Provider Demographics
NPI:1083637334
Name:CORNEJO, RIGO (DMD MD)
Entity type:Individual
Prefix:DR
First Name:RIGO
Middle Name:
Last Name:CORNEJO
Suffix:
Gender:M
Credentials:DMD MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 AVENUE K SE
Mailing Address - Street 2:SUITE #14A
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4145
Mailing Address - Country:US
Mailing Address - Phone:863-294-7648
Mailing Address - Fax:863-294-9045
Practice Address - Street 1:400 AVENUE K SE
Practice Address - Street 2:SUITE #14A
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4145
Practice Address - Country:US
Practice Address - Phone:863-294-7648
Practice Address - Fax:863-294-9045
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN152791223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54939ZMedicare ID - Type Unspecified
U81777Medicare UPIN