Healthcare Provider Details

I. General information

NPI: 1376631572
Provider Name (Legal Business Name): KOLB & KOLB DDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 08/22/2020
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 Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. PHILLIP W KOLB
Title or Position: PARTNER
Credential: DDS
Phone: 812-897-3470