Provider Demographics
NPI:1578911087
Name:COLGAN, JUSTIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:COLGAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 LONE OAK RD STE 1
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-8043
Mailing Address - Country:US
Mailing Address - Phone:270-556-0189
Mailing Address - Fax:
Practice Address - Street 1:2850 LONE OAK RD STE 1
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-8043
Practice Address - Country:US
Practice Address - Phone:270-554-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10050122300000X, 1223P0221X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program