Provider Demographics
NPI:1689309916
Name:LAURA A COLLATZ, DDS PA
Entity Type:Organization
Organization Name:LAURA A COLLATZ, DDS PA
Other - Org Name:ENCHANTING SMILES FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:A
Authorized Official - Last Name:COLLATZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, RDH, PA
Authorized Official - Phone:919-542-2712
Mailing Address - Street 1:360 WEST ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PITTSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27312-9448
Mailing Address - Country:US
Mailing Address - Phone:919-542-2712
Mailing Address - Fax:
Practice Address - Street 1:360 WEST ST STE 100
Practice Address - Street 2:
Practice Address - City:PITTSBORO
Practice Address - State:NC
Practice Address - Zip Code:27312-9448
Practice Address - Country:US
Practice Address - Phone:919-542-2712
Practice Address - Fax:919-542-7279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-20
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5913556Medicaid