Provider Demographics
NPI:1457465619
Name:COULTER, JOHN MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARK
Last Name:COULTER
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 1:102 FLAG LAKE DR STE C
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-6215
Mailing Address - Country:US
Mailing Address - Phone:979-297-1201
Mailing Address - Fax:979-297-6226
Practice Address - Street 1:102 FLAG LAKE DR STE C
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-6215
Practice Address - Country:US
Practice Address - Phone:979-297-1201
Practice Address - Fax:979-297-6226
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX136021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice