Healthcare Provider Details

I. General information

NPI: 1366575193
Provider Name (Legal Business Name): LINDA KAY COLTER D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 W NATIONAL AVE
BRAZIL IN
47834-2437
US

IV. Provider business mailing address

803 W NATIONAL AVE
BRAZIL IN
47834-2437
US

V. Phone/Fax

Practice location:
  • Phone: 812-446-2275
  • Fax: 812-446-6038
Mailing address:
  • Phone: 812-446-2275
  • Fax: 812-446-6038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12009712A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: