MEDICARE: MRS. BONNIE LOTT CORBIN RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	5479	NC

General Provider Information

NPI Number	:	1376637330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BONNIE LOTT CORBIN RDH

Provider Business Mailing Address
First Line	:	5624 MIDDLEFIELD PLACE
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28304
Country	:	US
Telephone Number	:	910-309-4822
Fax Number	:

Provider Business Practice Location Address
First Line	:	103 SUPERIOR DRIVE
Second Line	:
City	:	SPRING LAKE
State	:	NC
Zip	:	28390
Country	:	US
Telephone Number	:	910-497-3200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/08/2007

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