Provider Demographics
NPI:1285892695
Name:STREET, COLTON JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:COLTON
Middle Name:JOHN
Last Name:STREET
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2736 82ND ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-1428
Mailing Address - Country:US
Mailing Address - Phone:806-745-3381
Mailing Address - Fax:
Practice Address - Street 1:2736 82ND ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-1428
Practice Address - Country:US
Practice Address - Phone:806-745-3381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX239081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice