Provider Demographics
NPI:1396876272
Name:COULTER, HERBERT C (DDS)
Entity type:Individual
Prefix:DR
First Name:HERBERT
Middle Name:C
Last Name:COULTER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 SOUTH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BLAIR
Mailing Address - State:NE
Mailing Address - Zip Code:68008-1964
Mailing Address - Country:US
Mailing Address - Phone:402-426-3334
Mailing Address - Fax:402-426-4540
Practice Address - Street 1:1904 SOUTH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:BLAIR
Practice Address - State:NE
Practice Address - Zip Code:68008-1964
Practice Address - Country:US
Practice Address - Phone:402-426-3334
Practice Address - Fax:402-426-4540
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE38491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE3849OtherSTATE LICENSE
NE47052774500Medicaid