=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679388367
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLBY JAMES AESTHETIC DENTISTRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2025
-----------------------------------------------------
Last Update Date | 02/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1009 W WEBSTER AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-0519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-858-7067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1009 W WEBSTER AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-0519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-858-7067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/DENTIST
-----------------------------------------------------
Name | DR. COLBY J GERTH
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 217-663-2384
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------