MEDICARE: DR. HEATH R COLLEDGE D.M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	6620093-9922	UT
2	1223G0001X	General Practice Dentistry	5610	NV

General Provider Information

NPI Number	:	1679750756
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HEATH R COLLEDGE D.M.D

Provider Business Mailing Address
First Line	:	PO BOX 8
Second Line	:
City	:	ST GEORGE
State	:	UT
Zip	:	84771-0008
Country	:	US
Telephone Number	:	435-673-9606
Fax Number	:	435-673-6812

Provider Business Practice Location Address
First Line	:	427 W 100 S
Second Line	:
City	:	ST GEORGE
State	:	UT
Zip	:	84770-3375
Country	:	US
Telephone Number	:	435-673-9606
Fax Number	:	435-673-6812

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2008
Last Update Date	:	01/30/2008

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