Provider Demographics
NPI:1891928982
Name:COLBATH, STORMY IVIE (RDH)
Entity Type:Individual
Prefix:
First Name:STORMY
Middle Name:IVIE
Last Name:COLBATH
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 CIDER HILL RD
Mailing Address - Street 2:
Mailing Address - City:EXETER
Mailing Address - State:ME
Mailing Address - Zip Code:04435-3030
Mailing Address - Country:US
Mailing Address - Phone:207-379-2605
Mailing Address - Fax:
Practice Address - Street 1:195 CIDER HILL RD
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:ME
Practice Address - Zip Code:04435-3030
Practice Address - Country:US
Practice Address - Phone:207-379-2605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-24
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME2521124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME434519100Medicaid