Healthcare Provider Details

I. General information

NPI: 1790889046
Provider Name (Legal Business Name): JEFFREY P KOLB DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 W LOCUST ST
BOONVILLE IN
47601-0167
US

IV. Provider business mailing address

PO BOX 167 602 W LOCUST ST
BOONVILLE IN
47601-0167
US

V. Phone/Fax

Practice location:
  • Phone: 812-897-3470
  • Fax: 812-897-0068
Mailing address:
  • Phone: 812-897-3470
  • Fax: 812-897-0068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12008977
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: