MEDICARE: C HEATHER COLSON DMD PC

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	1223G0001X	General Practice Dentistry	DN012998	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1704152	OTHER		UNTD CONCORDIA DENTAL INS

General Provider Information

NPI Number	:	1124018759
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	C HEATHER COLSON DMD PC

Provider Business Mailing Address
First Line	:	PO BOX 3816
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31604-3816
Country	:	US
Telephone Number	:	229-242-2449
Fax Number	:	229-242-2699

Provider Business Practice Location Address
First Line	:	3000 N PATTERSON ST
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31602-1711
Country	:	US
Telephone Number	:	229-242-2449
Fax Number	:	229-242-2699

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	DR. CATHERINE HEATHER COLSON HARDY
Credential	:	DMD
Telephone Number	:	229-242-2449

Provider Enumeration Date	:	10/25/2005
Last Update Date	:	05/07/2012

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