1790764777 NPI number — DR. MARYJO NMI CORBETT DDS

Table of content: DR. MARYJO NMI CORBETT DDS (NPI 1790764777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790764777 NPI number — DR. MARYJO NMI CORBETT DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORBETT
Provider First Name:
MARYJO
Provider Middle Name:
NMI
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790764777
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
HEIDELBERG DENTAL ACTIVITY
Provider Second Line Business Mailing Address:
CMR 442 ATTN:MR HAMMOND
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AE
Provider Business Mailing Address Postal Code:
09042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HEIDELBERG DENTAL ACTIVITY
Provider Second Line Business Practice Location Address:
CMR 442 ATTN:MR HAMMOND
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AE
Provider Business Practice Location Address Postal Code:
09042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
011943143712288
Provider Business Practice Location Address Fax Number:
011943143712288
Provider Enumeration Date:
01/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  019-019189 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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