Provider Demographics
NPI:1154685956
Name:SMITH, COLIN TOLLERTON JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:COLIN
Middle Name:TOLLERTON
Last Name:SMITH
Suffix:JR
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 1:24189 ERMINE DR
Mailing Address - Street 2:
Mailing Address - City:LINNEUS
Mailing Address - State:MO
Mailing Address - Zip Code:64653-9215
Mailing Address - Country:US
Mailing Address - Phone:816-392-5077
Mailing Address - Fax:
Practice Address - Street 1:13051 S HWY 71
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030
Practice Address - Country:US
Practice Address - Phone:816-425-2446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012019399122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist