Provider Demographics
NPI:1235353335
Name:JOHN M. COLBERT, DMD, LLC
Entity Type:Organization
Organization Name:JOHN M. COLBERT, DMD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-787-2547
Mailing Address - Street 1:997 CLOCK TOWER DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-1301
Mailing Address - Country:US
Mailing Address - Phone:217-787-2547
Mailing Address - Fax:217-787-1757
Practice Address - Street 1:997 CLOCK TOWER DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-1301
Practice Address - Country:US
Practice Address - Phone:217-787-2547
Practice Address - Fax:217-787-1757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty