Provider Demographics
NPI:1538389093
Name:COLBERT, MICHAEL LAWRENCE (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:COLBERT
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 1:10182 LANCASTER LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-3562
Mailing Address - Country:US
Mailing Address - Phone:763-424-4544
Mailing Address - Fax:763-424-2269
Practice Address - Street 1:10182 LANCASTER LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-3562
Practice Address - Country:US
Practice Address - Phone:763-424-4544
Practice Address - Fax:763-424-2269
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN86321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice