Provider Demographics
NPI:1366621435
Name:TABERT, CORINNE ELLEN (DDS)
Entity type:Individual
Prefix:
First Name:CORINNE
Middle Name:ELLEN
Last Name:TABERT
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 1:21676 POTOMAC VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-2134
Mailing Address - Country:US
Mailing Address - Phone:402-202-4148
Mailing Address - Fax:
Practice Address - Street 1:29795 THREE NOTCH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE HALL
Practice Address - State:MD
Practice Address - Zip Code:20622-4106
Practice Address - Country:US
Practice Address - Phone:301-290-0001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014119051223G0001X
CA63964122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice