Healthcare Provider Details

I. General information

NPI: 1285761692
Provider Name (Legal Business Name): LOLA COLBERT DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4353 ATLANTA HWY
LOGANVILLE GA
30052-3214
US

IV. Provider business mailing address

1173 GRASSMEADE WAY
SNELLVILLE GA
30078-7797
US

V. Phone/Fax

Practice location:
  • Phone: 770-450-2030
  • Fax:
Mailing address:
  • Phone: 718-930-3684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN012997
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number051535
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: