Provider Demographics
NPI:1992545677
Name:CORNEJO, MIRANDA RHIA (DDS)
Entity type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:RHIA
Last Name:CORNEJO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 RIDGE RD STE A
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1571
Mailing Address - Country:US
Mailing Address - Phone:219-315-0769
Mailing Address - Fax:
Practice Address - Street 1:417 RIDGE RD STE A
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1571
Practice Address - Country:US
Practice Address - Phone:219-552-7674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-29
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014437A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice