Provider Demographics
NPI:1083650881
Name:COLLINS & SAMPSON DDS PA
Entity Type:Organization
Organization Name:COLLINS & SAMPSON DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANE COORDNATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEA
Authorized Official - Middle Name:B
Authorized Official - Last Name:HUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-521-8646
Mailing Address - Street 1:312 E. WARDELL RD
Mailing Address - Street 2:PO BOX 2049
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-9262
Mailing Address - Country:US
Mailing Address - Phone:910-521-8646
Mailing Address - Fax:910-521-8643
Practice Address - Street 1:312 E. WARDELL RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-9262
Practice Address - Country:US
Practice Address - Phone:910-521-8646
Practice Address - Fax:910-521-8643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC08361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890116XMedicaid
NC8991735Medicaid
NCU37838Medicare UPIN
NC8991735Medicaid