=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366574378
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN G CORBETT LD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 NW 3RD AVE
-----------------------------------------------------
City | CANBY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97013-3603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-266-1800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6799 SW ALDEN ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97223-1328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-244-7355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122400000X
-----------------------------------------------------
Taxonomy Name | Denturist
-----------------------------------------------------
License Number | DT-DO-643631
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------