Provider Demographics
NPI:1952398497
Name:COLBERT, KENNETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:COLBERT
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 1:389 W HIGHWAY 8
Mailing Address - Street 2:
Mailing Address - City:STEELVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65565-4582
Mailing Address - Country:US
Mailing Address - Phone:573-775-2867
Mailing Address - Fax:
Practice Address - Street 1:204 W MAIN
Practice Address - Street 2:
Practice Address - City:STEELVILLE
Practice Address - State:MO
Practice Address - Zip Code:65565
Practice Address - Country:US
Practice Address - Phone:573-775-2636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO133051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO103500OtherBLUE CROSS/BS PROV. #