Provider Demographics
NPI:1710119136
Name:MEL COLLAZO, DDS, MS, PA
Entity Type:Organization
Organization Name:MEL COLLAZO, DDS, MS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLAZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-221-0004
Mailing Address - Street 1:11811 HINSON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-3472
Mailing Address - Country:US
Mailing Address - Phone:501-221-0004
Mailing Address - Fax:501-219-0300
Practice Address - Street 1:11811 HINSON RD STE 100
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-3472
Practice Address - Country:US
Practice Address - Phone:501-221-0004
Practice Address - Fax:501-219-0300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR27491223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty