Provider Demographics
NPI:1558385278
Name:COLLINS, MARK ANTHONY (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:COLLINS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3088 APPALACHIAN HWY STE 2
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757-2526
Mailing Address - Country:US
Mailing Address - Phone:423-566-8248
Mailing Address - Fax:423-566-8247
Practice Address - Street 1:3088 APPALACHIAN HWY STE 2
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TN
Practice Address - Zip Code:37757-2526
Practice Address - Country:US
Practice Address - Phone:423-566-8248
Practice Address - Fax:423-566-8247
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8223122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN9176866TMedicaid