Provider Demographics
NPI:1700106341
Name:DOUGLAS, COLTON C (DMD)
Entity Type:Individual
Prefix:DR
First Name:COLTON
Middle Name:C
Last Name:DOUGLAS
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 1:36 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANTI
Mailing Address - State:UT
Mailing Address - Zip Code:84642-1254
Mailing Address - Country:US
Mailing Address - Phone:435-851-6411
Mailing Address - Fax:
Practice Address - Street 1:36 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MANTI
Practice Address - State:UT
Practice Address - Zip Code:84642-1254
Practice Address - Country:US
Practice Address - Phone:435-590-8917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-05
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT768517499221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice