Provider Demographics
NPI:1750959110
Name:DESSERT, COLTON KEN
Entity type:Individual
Prefix:
First Name:COLTON
Middle Name:KEN
Last Name:DESSERT
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 1:9132 TRUEMPER STREET
Mailing Address - Street 2:UNIT 9132
Mailing Address - City:LACKLAND AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78236
Mailing Address - Country:US
Mailing Address - Phone:916-865-7567
Mailing Address - Fax:
Practice Address - Street 1:2200 BERGQUIST DR STE 1
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-9908
Practice Address - Country:US
Practice Address - Phone:210-292-7412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider