Provider Demographics
NPI:1396836607
Name:COLVIN, MICHAEL JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:COLVIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-2949
Mailing Address - Country:US
Mailing Address - Phone:608-783-8390
Mailing Address - Fax:608-783-8385
Practice Address - Street 1:300 MAIN ST
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-2949
Practice Address - Country:US
Practice Address - Phone:608-783-8390
Practice Address - Fax:608-783-8385
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2933-0151223G0001X
MND93881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33443200Medicaid
WI391410802Medicare UPIN