Provider Demographics
NPI:1457794190
Name:STRUB, COLIN TRESTER (DDS)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:TRESTER
Last Name:STRUB
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 1:2155 BENTON BLVD
Mailing Address - Street 2:APT 15303
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-1991
Mailing Address - Country:US
Mailing Address - Phone:920-207-3988
Mailing Address - Fax:
Practice Address - Street 1:125 SOUTHERN JUNCTION BLVD
Practice Address - Street 2:SUITE 701
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-2214
Practice Address - Country:US
Practice Address - Phone:912-330-4545
Practice Address - Fax:888-629-3621
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-11
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice