MEDICARE: DR. LOLA COLBERT 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	1223G0001X	General Practice Dentistry	051535	NY
2	122300000X	Dentist	DN012997	GA

General Provider Information

NPI Number	:	1285761692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LOLA COLBERT DDS

Provider Business Mailing Address
First Line	:	1173 GRASSMEADE WAY
Second Line	:
City	:	SNELLVILLE
State	:	GA
Zip	:	30078-7797
Country	:	US
Telephone Number	:	718-930-3684
Fax Number	:

Provider Business Practice Location Address
First Line	:	4353 ATLANTA HWY
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-3214
Country	:	US
Telephone Number	:	770-450-2030
Fax Number	:

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

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	02/15/2022

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