Provider Demographics
NPI:1396837530
Name:COLWELL, GARY WILLIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:WILLIS
Last Name:COLWELL
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 1:906 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:IA
Mailing Address - Zip Code:50003
Mailing Address - Country:US
Mailing Address - Phone:515-993-3522
Mailing Address - Fax:515-993-4600
Practice Address - Street 1:906 MAIN STREET
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:IA
Practice Address - Zip Code:50003
Practice Address - Country:US
Practice Address - Phone:515-993-3522
Practice Address - Fax:515-993-4600
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA5678122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0119222Medicaid