Provider Demographics
NPI:1497280358
Name:COLLAZO, AUSTIN CHARLES (DDS)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:CHARLES
Last Name:COLLAZO
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 1:617 N DOHENY DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-3526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14248 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-7008
Practice Address - Country:US
Practice Address - Phone:501-247-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108679122300000X
CODEN.00203202122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1497280358Medicaid