Provider Demographics
NPI:1508951575
Name:COALSON, REBECCA LEE (DMD)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:LEE
Last Name:COALSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MISS
Other - First Name:REBECCA
Other - Middle Name:LEE
Other - Last Name:BAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:2 TERMINAL DR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024-2268
Mailing Address - Country:US
Mailing Address - Phone:618-259-1419
Mailing Address - Fax:618-259-1502
Practice Address - Street 1:2 TERMINAL DR
Practice Address - Street 2:SUITE 8
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-2268
Practice Address - Country:US
Practice Address - Phone:618-259-1419
Practice Address - Fax:618-259-1502
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026829122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019026829Medicaid