Provider Demographics
NPI:1508134289
Name:REID, COLLIN VAUGHN CRAIG (DDS01/06/)
Entity Type:Individual
Prefix:DR
First Name:COLLIN
Middle Name:VAUGHN CRAIG
Last Name:REID
Suffix:
Gender:M
Credentials:DDS01/06/
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 E BIJOU ST STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-8009
Mailing Address - Country:US
Mailing Address - Phone:719-576-1850
Mailing Address - Fax:719-955-3470
Practice Address - Street 1:1901 W 21ST ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203
Practice Address - Country:US
Practice Address - Phone:316-832-2838
Practice Address - Fax:316-832-9530
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS613101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1508134289Medicaid