Provider Demographics
NPI:1295366896
Name:COLLINSVILLE PEDIATRIC DENTISTRY PLLC
Entity Type:Organization
Organization Name:COLLINSVILLE PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:
Authorized Official - Last Name:HASTINGS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:618-346-8000
Mailing Address - Street 1:90 CRESTMOOR ST
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-4951
Mailing Address - Country:US
Mailing Address - Phone:618-346-8000
Mailing Address - Fax:
Practice Address - Street 1:90 CRESTMOOR ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-4951
Practice Address - Country:US
Practice Address - Phone:618-346-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-01
Last Update Date:2020-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty