MEDICARE: JACK BRADY COLOMBIN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	5833	OK

General Provider Information

NPI Number	:	1073581559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK BRADY COLOMBIN DDS

Provider Business Mailing Address
First Line	:	1390 W CHEROKEE ST
Second Line	:
City	:	CLEVELAND
State	:	OK
Zip	:	74020-4044
Country	:	US
Telephone Number	:	918-358-2300
Fax Number	:	918-358-2302

Provider Business Practice Location Address
First Line	:	1390 W CHEROKEE ST
Second Line	:	CLEVELAND SMILES
City	:	CLEVELAND
State	:	OK
Zip	:	74020-4044
Country	:	US
Telephone Number	:	918-358-2300
Fax Number	:	918-358-2302

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	07/02/2012

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