Provider Demographics
NPI:1437602638
Name:MOHN, COLLEEN MARIE (DMD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIE
Last Name:MOHN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25719 N 54TH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-1869
Mailing Address - Country:US
Mailing Address - Phone:602-881-3651
Mailing Address - Fax:
Practice Address - Street 1:4400 N MIDKIFF RD
Practice Address - Street 2:STE A-1
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-4219
Practice Address - Country:US
Practice Address - Phone:432-689-4867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32034122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist