Provider Demographics
NPI:1821615139
Name:GERTH, COLBY J (DMD)
Entity Type:Individual
Prefix:
First Name:COLBY
Middle Name:J
Last Name:GERTH
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 1:9990 W 190TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8189
Mailing Address - Country:US
Mailing Address - Phone:708-479-9797
Mailing Address - Fax:
Practice Address - Street 1:9990 W 190TH ST STE D
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8189
Practice Address - Country:US
Practice Address - Phone:708-479-9797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0325961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice