Provider Demographics
NPI:1659536399
Name:COLTON DENTAL GROUP
Entity Type:Organization
Organization Name:COLTON DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:DASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-825-0545
Mailing Address - Street 1:251 E VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3005
Mailing Address - Country:US
Mailing Address - Phone:909-825-0545
Mailing Address - Fax:
Practice Address - Street 1:251 E VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3005
Practice Address - Country:US
Practice Address - Phone:909-825-0545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLTON DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41386122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty