Provider Demographics
NPI:1124018759
Name:C HEATHER COLSON DMD PC
Entity Type:Organization
Organization Name:C HEATHER COLSON DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:HEATHER
Authorized Official - Last Name:COLSON HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:229-242-2449
Mailing Address - Street 1:PO BOX 3816
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31604-3816
Mailing Address - Country:US
Mailing Address - Phone:229-242-2449
Mailing Address - Fax:229-242-2699
Practice Address - Street 1:3000 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1711
Practice Address - Country:US
Practice Address - Phone:229-242-2449
Practice Address - Fax:229-242-2699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0129981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA853466232AMedicaid
1704152OtherUNTD CONCORDIA DENTAL INS