Provider Demographics
NPI:1407902562
Name:ITO, COLLIN NOBU (DMD)
Entity Type:Individual
Prefix:DR
First Name:COLLIN
Middle Name:NOBU
Last Name:ITO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4909 E CHANDLER BLVD
Mailing Address - Street 2:#501
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0863
Mailing Address - Country:US
Mailing Address - Phone:480-785-9191
Mailing Address - Fax:480-785-9197
Practice Address - Street 1:4909 E CHANDLER BLVD
Practice Address - Street 2:#501
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-0863
Practice Address - Country:US
Practice Address - Phone:480-785-9191
Practice Address - Fax:480-785-9197
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD53101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice