Healthcare Provider Details

I. General information

NPI: 1750959110
Provider Name (Legal Business Name): COLTON KEN DESSERT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 06/14/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 BERGQUIST DR STE 1
JBSA LACKLAND TX
78236-9908
US

IV. Provider business mailing address

9132 TRUEMPER STREET UNIT 9132
LACKLAND AFB TX
78236
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-7412
  • Fax:
Mailing address:
  • Phone: 916-865-7567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: