Provider Demographics
NPI:1922217298
Name:COLVARD, MICHAEL
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:COLVARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24871 N WILDBERRY BEND
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013
Mailing Address - Country:US
Mailing Address - Phone:847-490-3980
Mailing Address - Fax:
Practice Address - Street 1:24871 N WILDBERRY BND
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:IL
Practice Address - Zip Code:60013-2349
Practice Address - Country:US
Practice Address - Phone:847-490-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics