Provider Demographics
NPI:1285761692
Name:COLBERT, LOLA (DDS)
Entity type:Individual
Prefix:DR
First Name:LOLA
Middle Name:
Last Name:COLBERT
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 1:1173 GRASSMEADE WAY
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-7797
Mailing Address - Country:US
Mailing Address - Phone:718-930-3684
Mailing Address - Fax:
Practice Address - Street 1:4353 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-3214
Practice Address - Country:US
Practice Address - Phone:770-450-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0515351223G0001X
GADN012997122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice