Provider Demographics
NPI:1457661647
Name:CORBETT W SUMMERS DDS
Entity Type:Organization
Organization Name:CORBETT W SUMMERS DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORBETT
Authorized Official - Middle Name:W
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-442-6141
Mailing Address - Street 1:777 29TH ST.
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303
Mailing Address - Country:US
Mailing Address - Phone:303-442-6141
Mailing Address - Fax:303-545-5669
Practice Address - Street 1:777 29TH ST.
Practice Address - Street 2:SUITE 300
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303
Practice Address - Country:US
Practice Address - Phone:303-442-6141
Practice Address - Fax:303-545-5669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO51291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1548480486Medicaid