Provider Demographics
NPI:1073581559
Name:COLOMBIN, JACK BRADY (DDS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:BRADY
Last Name:COLOMBIN
Suffix:
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 1:1390 W CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OK
Mailing Address - Zip Code:74020-4044
Mailing Address - Country:US
Mailing Address - Phone:918-358-2300
Mailing Address - Fax:918-358-2302
Practice Address - Street 1:1390 W CHEROKEE ST
Practice Address - Street 2:CLEVELAND SMILES
Practice Address - City:CLEVELAND
Practice Address - State:OK
Practice Address - Zip Code:74020-4044
Practice Address - Country:US
Practice Address - Phone:918-358-2300
Practice Address - Fax:918-358-2302
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5833122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist