Provider Demographics
NPI:1336320621
Name:COLLINS ORAL & MAXILLOFACIAL SURGERY, PS
Entity Type:Organization
Organization Name:COLLINS ORAL & MAXILLOFACIAL SURGERY, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-624-2204
Mailing Address - Street 1:322 W 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2504
Mailing Address - Country:US
Mailing Address - Phone:509-624-2202
Mailing Address - Fax:
Practice Address - Street 1:322 W 7TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2504
Practice Address - Country:US
Practice Address - Phone:509-624-2202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5035753Medicaid
WA5035753Medicaid