Provider Demographics
NPI:1770072860
Name:COLGAN PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:COLGAN PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-554-3131
Mailing Address - Street 1:2850 LONE OAK RD STE 1
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-8043
Mailing Address - Country:US
Mailing Address - Phone:270-554-0124
Mailing Address - Fax:270-554-0124
Practice Address - Street 1:2850 LONE OAK RD STE 1
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-8043
Practice Address - Country:US
Practice Address - Phone:270-554-0124
Practice Address - Fax:270-554-0124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty