Provider Demographics
NPI:1407979107
Name:COLLIER, EVELYN WINFORD (DMD)
Entity Type:Individual
Prefix:DR
First Name:EVELYN
Middle Name:WINFORD
Last Name:COLLIER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:EVELYN
Other - Middle Name:WINFORD
Other - Last Name:COLLIER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:1090 NORTHCHASE PKWY SE
Mailing Address - Street 2:STE. 290
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-6405
Mailing Address - Country:US
Mailing Address - Phone:678-904-5665
Mailing Address - Fax:678-247-7862
Practice Address - Street 1:2650 BEACH BLVD
Practice Address - Street 2:STE. 31
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4517
Practice Address - Country:US
Practice Address - Phone:228-273-1689
Practice Address - Fax:228-388-2051
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2892-951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660217Medicaid