Provider Demographics
NPI:1275010514
Name:COLLINS, ANDREA ELIZABETH LEA (DDS)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:ELIZABETH LEA
Last Name:COLLINS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 NW FRONT AVE APT 108
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1858
Mailing Address - Country:US
Mailing Address - Phone:814-602-0954
Mailing Address - Fax:
Practice Address - Street 1:13831 NW CORNELL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5485
Practice Address - Country:US
Practice Address - Phone:503-718-3762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD108591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice