Healthcare Provider Details

I. General information

NPI: 1558950964
Provider Name (Legal Business Name): COLTON LAWRENCE FOWLKES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 CANTON RD NE STE 100
MARIETTA GA
30060-7283
US

IV. Provider business mailing address

2825 PARNELL SPRINGS CT
CUMMING GA
30040-5027
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-8264
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN122221
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN122221
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: