Provider Demographics
NPI:1700044195
Name:CHARLES D KOLB DDS INC
Entity Type:Organization
Organization Name:CHARLES D KOLB DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:KOLB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:361-528-3262
Mailing Address - Street 1:PO BOX 212
Mailing Address - Street 2:
Mailing Address - City:TAFT
Mailing Address - State:TX
Mailing Address - Zip Code:78390-0212
Mailing Address - Country:US
Mailing Address - Phone:361-528-3262
Mailing Address - Fax:361-528-2016
Practice Address - Street 1:1210 GREGORY ST
Practice Address - Street 2:STE 3
Practice Address - City:TAFT
Practice Address - State:TX
Practice Address - Zip Code:78390-0212
Practice Address - Country:US
Practice Address - Phone:361-528-3262
Practice Address - Fax:361-528-2016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX93331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG6016501OtherCHIP
TX009129001Medicaid