Provider Demographics
NPI:1790764777
Name:CORBETT, MARYJO NMI (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARYJO
Middle Name:NMI
Last Name:CORBETT
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:HEIDELBERG DENTAL ACTIVITY
Mailing Address - Street 2:CMR 442 ATTN:MR HAMMOND
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HEIDELBERG DENTAL ACTIVITY
Practice Address - Street 2:CMR 442 ATTN:MR HAMMOND
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09042
Practice Address - Country:US
Practice Address - Phone:01194314-371-2288
Practice Address - Fax:01194314-371-2288
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0191891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
BC7248506OtherFEDERAL DEA