Provider Demographics
NPI:1104276443
Name:COLBURN, KATELYNN
Entity type:Individual
Prefix:DR
First Name:KATELYNN
Middle Name:
Last Name:COLBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 PARK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RIVER RIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70123-1182
Mailing Address - Country:US
Mailing Address - Phone:504-491-8575
Mailing Address - Fax:
Practice Address - Street 1:850 N CANAL BLVD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-8076
Practice Address - Country:US
Practice Address - Phone:985-447-4783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6688122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist