Provider Demographics
NPI:1164843132
Name:COLINA DENTAL CENTER
Entity Type:Organization
Organization Name:COLINA DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:COLINA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:804-241-4851
Mailing Address - Street 1:PO BOX 1237, 1646 TAPP BLVD
Mailing Address - Street 2:
Mailing Address - City:TAPPAHANNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22560-1237
Mailing Address - Country:US
Mailing Address - Phone:804-443-5984
Mailing Address - Fax:804-443-3462
Practice Address - Street 1:1646 TAPPAHANNOCK BLVD
Practice Address - Street 2:
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560-9346
Practice Address - Country:US
Practice Address - Phone:804-443-5984
Practice Address - Fax:804-443-3462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401007889122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty