Provider Demographics
NPI:1376623280
Name:T. COOPER COLQUITT, DDS, MSD, PC
Entity Type:Organization
Organization Name:T. COOPER COLQUITT, DDS, MSD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:COOPER
Authorized Official - Last Name:COLQUITT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:205-785-7901
Mailing Address - Street 1:401 TUSCALOOSA AVE SW
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35211-1416
Mailing Address - Country:US
Mailing Address - Phone:205-785-7901
Mailing Address - Fax:205-785-7904
Practice Address - Street 1:401 TUSCALOOSA AVE SW
Practice Address - Street 2:SUITE 210
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211-1416
Practice Address - Country:US
Practice Address - Phone:205-785-7901
Practice Address - Fax:205-785-7904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL50331223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
96964Medicare UPIN