Provider Demographics
NPI:1699529164
Name:CORNEJO, ALYSSA MIA (DMD)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MIA
Last Name:CORNEJO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14141 CEDAR RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-3209
Mailing Address - Country:US
Mailing Address - Phone:216-382-6600
Mailing Address - Fax:
Practice Address - Street 1:14141 CEDAR RD
Practice Address - Street 2:
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-3209
Practice Address - Country:US
Practice Address - Phone:216-382-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-12
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.027555122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist