Healthcare Provider Details

I. General information

NPI: 1245526722
Provider Name (Legal Business Name): CORBETT A HAAS DDS,MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 07/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 32ND AVE S
FARGO ND
58103
US

IV. Provider business mailing address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-8000
  • Fax:
Mailing address:
  • Phone: 701-364-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDL-11263
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number15144
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: