Provider Demographics
NPI:1275629909
Name:COLEMAN, GEORGE MACKAY JR (DMD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:MACKAY
Last Name:COLEMAN
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3739 ELM ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-4345
Mailing Address - Country:US
Mailing Address - Phone:636-443-2329
Mailing Address - Fax:
Practice Address - Street 1:14220 OLD HALLS FERRY ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63034
Practice Address - Country:US
Practice Address - Phone:314-355-2838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO013199122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist