Provider Demographics
NPI:1174657621
Name:COLBERT, KIRK
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:
Last Name:COLBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 PRAIRIE AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4867
Mailing Address - Country:US
Mailing Address - Phone:307-632-6512
Mailing Address - Fax:
Practice Address - Street 1:1331 PRAIRIE AVE STE 4
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4867
Practice Address - Country:US
Practice Address - Phone:307-632-6512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYWYO 7601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice