Provider Demographics
NPI:1073534673
Name:COLVIN, SHERRY C (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHERRY
Middle Name:C
Last Name:COLVIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 FORREST STREET EXT
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-7056
Mailing Address - Country:US
Mailing Address - Phone:229-244-8884
Mailing Address - Fax:229-244-8874
Practice Address - Street 1:3901 FORREST STREET EXT
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-7056
Practice Address - Country:US
Practice Address - Phone:229-244-8884
Practice Address - Fax:229-244-8874
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA123021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000910324AMedicaid