Provider Demographics
NPI:1508024811
Name:MASTERS, COLLEEN J (RDH)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:J
Last Name:MASTERS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1067 25TH ST
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:WI
Mailing Address - Zip Code:54822-9750
Mailing Address - Country:US
Mailing Address - Phone:715-859-6204
Mailing Address - Fax:
Practice Address - Street 1:1067 25TH ST
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:WI
Practice Address - Zip Code:54822-9750
Practice Address - Country:US
Practice Address - Phone:715-859-6204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3773124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist