Provider Demographics
NPI:1881742393
Name:COLTER, JENNIFER DIANE (DDS)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:DIANE
Last Name:COLTER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5211 FOREST LN STE 127
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-8038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5211 FOREST LN STE 127
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-8038
Practice Address - Country:US
Practice Address - Phone:972-233-4439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201111223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG60008-1OtherCHIP PROVIDER NUMBER
TX1747685Medicaid
TX0033BTOtherBLUE CROSS BLUE SHIELD #