Healthcare Provider Details

I. General information

NPI: 1366621435
Provider Name (Legal Business Name): CORINNE ELLEN TABERT DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29795 THREE NOTCH RD
CHARLOTTE HALL MD
20622-4106
US

IV. Provider business mailing address

21676 POTOMAC VIEW DR
LEONARDTOWN MD
20650-2134
US

V. Phone/Fax

Practice location:
  • Phone: 301-290-0001
  • Fax:
Mailing address:
  • Phone: 402-202-4148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number63964
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401411905
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: