Provider Demographics
NPI:1659933190
Name:ROBERTSON, COLLENA (DMD)
Entity Type:Individual
Prefix:DR
First Name:COLLENA
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 GRANDVIEW PKWY APT 314
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35243-2095
Mailing Address - Country:US
Mailing Address - Phone:704-249-7657
Mailing Address - Fax:
Practice Address - Street 1:1316 NOBLE ST
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36201-4643
Practice Address - Country:US
Practice Address - Phone:256-492-0131
Practice Address - Fax:256-235-2019
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0006643-C11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice