Provider Demographics
NPI:1750852182
Name:DEREK M CORNETTA, DDS, PC
Entity Type:Organization
Organization Name:DEREK M CORNETTA, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:M
Authorized Official - Last Name:CORNETTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:774-254-0869
Mailing Address - Street 1:36 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ASSONET
Mailing Address - State:MA
Mailing Address - Zip Code:02702-1710
Mailing Address - Country:US
Mailing Address - Phone:508-644-5200
Mailing Address - Fax:
Practice Address - Street 1:36 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ASSONET
Practice Address - State:MA
Practice Address - Zip Code:02702-1710
Practice Address - Country:US
Practice Address - Phone:508-644-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental