Healthcare Provider Details

I. General information

NPI: 1952398497
Provider Name (Legal Business Name): KENNETH COLBERT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 W MAIN
STEELVILLE MO
65565
US

IV. Provider business mailing address

389 W HIGHWAY 8
STEELVILLE MO
65565-4582
US

V. Phone/Fax

Practice location:
  • Phone: 573-775-2636
  • Fax:
Mailing address:
  • Phone: 573-775-2867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13305
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: