Healthcare Provider Details

I. General information

NPI: 1114511656
Provider Name (Legal Business Name): COULON DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2021
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 N GARFIELD ST STE 220
MIDLAND TX
79705-6417
US

IV. Provider business mailing address

3000 N GARFIELD ST STE 220
MIDLAND TX
79705-6417
US

V. Phone/Fax

Practice location:
  • Phone: 432-683-5313
  • Fax:
Mailing address:
  • Phone: 432-683-5313
  • Fax:

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: KACI AWBREY
Title or Position: OFFICE FACILITATOR
Credential:
Phone: 432-238-4146