Healthcare Provider Details

I. General information

NPI: 1568761278
Provider Name (Legal Business Name): CORI ANNA GARRETT DH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 SOUTH 30TH STREET SUITE 103
OMAHA NE
68107-1656
US

IV. Provider business mailing address

4920 SOUTH 30TH STREET SUITE 103
OMAHA NE
68107-1656
US

V. Phone/Fax

Practice location:
  • Phone: 402-734-4110
  • Fax: 402-991-5642
Mailing address:
  • Phone: 402-734-4110
  • Fax: 402-991-5642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number828
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number1930
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: