Healthcare Provider Details

I. General information

NPI: 1063579449
Provider Name (Legal Business Name): CHARISSE COLBERT DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4105 DOWLEN RD SUITE A
BEAUMONT TX
77706-6874
US

IV. Provider business mailing address

4105 DOWLEN RD SUITE A
BEAUMONT TX
77706-6874
US

V. Phone/Fax

Practice location:
  • Phone: 409-924-8100
  • Fax: 409-924-8181
Mailing address:
  • Phone: 409-924-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17066
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: