Provider Demographics
NPI:1073920864
Name:COULON DENTAL CARE
Entity Type:Organization
Organization Name:COULON DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-683-5313
Mailing Address - Street 1:3000 N GARFIELD ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-6400
Mailing Address - Country:US
Mailing Address - Phone:432-683-5313
Mailing Address - Fax:432-683-8195
Practice Address - Street 1:3000 N GARFIELD ST
Practice Address - Street 2:SUITE 220
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-6400
Practice Address - Country:US
Practice Address - Phone:432-683-5313
Practice Address - Fax:432-683-8195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30078122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty