Provider Demographics
NPI:1851481808
Name:COLBERT, JOHN MICHAEL (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:COLBERT
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 1:997 CLOCK TOWER DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-1301
Mailing Address - Country:US
Mailing Address - Phone:217-787-2547
Mailing Address - Fax:217-787-1757
Practice Address - Street 1:997 CLOCK TOWER DR
Practice Address - Street 2:SUITE D
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-1301
Practice Address - Country:US
Practice Address - Phone:217-787-2547
Practice Address - Fax:217-787-1757
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice