Provider Demographics
NPI:1427032671
Name:COLLINS, RAYMOND F (DDS)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:F
Last Name:COLLINS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BLUE HOLE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88435-2533
Mailing Address - Country:US
Mailing Address - Phone:505-718-6899
Mailing Address - Fax:
Practice Address - Street 1:1000 BLUE HOLE DRIVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:NM
Practice Address - Zip Code:88435-2533
Practice Address - Country:US
Practice Address - Phone:505-718-6899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2469122300000X
NE64431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE5487OtherBCBS PROVIDER ID
NE47071268402Medicaid