Provider Demographics
NPI:1548480486
Name:SUMMERS, CORBETT WILLIAM II (DDS)
Entity type:Individual
Prefix:DR
First Name:CORBETT
Middle Name:WILLIAM
Last Name:SUMMERS
Suffix:II
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 29TH ST
Mailing Address - Street 2:SUITE #300
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2358
Mailing Address - Country:US
Mailing Address - Phone:303-442-6141
Mailing Address - Fax:303-545-5669
Practice Address - Street 1:777 29TH ST
Practice Address - Street 2:SUITE #300
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2358
Practice Address - Country:US
Practice Address - Phone:303-442-6141
Practice Address - Fax:303-545-5669
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO51291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO5129Medicaid