Provider Demographics
NPI:1245779792
Name:COLTON DENTAL GROUP
Entity Type:Organization
Organization Name:COLTON DENTAL GROUP
Other - Org Name:EAST WEST FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:TARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-384-1020
Mailing Address - Street 1:2495 EAST-WEST CONNECTOR
Mailing Address - Street 2:STE 60
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106
Mailing Address - Country:US
Mailing Address - Phone:678-384-1020
Mailing Address - Fax:
Practice Address - Street 1:2495 EAST-WEST CONNECTOR
Practice Address - Street 2:STE 60
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106
Practice Address - Country:US
Practice Address - Phone:678-384-1020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013527261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental