Provider Demographics
NPI:1154622173
Name:COLOMBARO, PHYLLIS A (DDS)
Entity type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:A
Last Name:COLOMBARO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 MT. AETNA RD.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6832
Mailing Address - Country:US
Mailing Address - Phone:301-739-3535
Mailing Address - Fax:301-739-8111
Practice Address - Street 1:1185 MT. AETNA RD.
Practice Address - Street 2:SUITE 200
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6832
Practice Address - Country:US
Practice Address - Phone:301-739-3535
Practice Address - Fax:301-739-8111
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD096641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice