Provider Demographics
NPI:1386023992
Name:COLLEEN POOL DENTISTRY LLC
Entity Type:Organization
Organization Name:COLLEEN POOL DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:POOL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-861-4484
Mailing Address - Street 1:PO BOX 565
Mailing Address - Street 2:
Mailing Address - City:NEW PALESTINE
Mailing Address - State:IN
Mailing Address - Zip Code:46163-0565
Mailing Address - Country:US
Mailing Address - Phone:317-861-4484
Mailing Address - Fax:317-861-8339
Practice Address - Street 1:5774 W US 52
Practice Address - Street 2:
Practice Address - City:NEW PALESTINE
Practice Address - State:IN
Practice Address - Zip Code:46163-0565
Practice Address - Country:US
Practice Address - Phone:317-861-4484
Practice Address - Fax:317-861-8339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010842B122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty