Provider Demographics
NPI:1598844748
Name:KILCOLLIN, MARK C (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
Last Name:KILCOLLIN
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:PO BOX 618
Mailing Address - Street 2:HEALTH CENTER DRIVE
Mailing Address - City:UNION
Mailing Address - State:WV
Mailing Address - Zip Code:24983-0618
Mailing Address - Country:US
Mailing Address - Phone:304-772-3333
Mailing Address - Fax:304-772-3512
Practice Address - Street 1:HEALTH CENTER DRIVE
Practice Address - Street 2:HEALTH CENTER BUILDING
Practice Address - City:UNION
Practice Address - State:WV
Practice Address - Zip Code:24983
Practice Address - Country:US
Practice Address - Phone:304-772-3333
Practice Address - Fax:304-772-3512
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2092122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0135408000Medicaid
WV0135408000Medicaid