Provider Demographics
NPI:1710317326
Name:K.O.A.L.A. DENTAL CARE, LLC
Entity Type:Organization
Organization Name:K.O.A.L.A. DENTAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:COLLIER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-253-8380
Mailing Address - Street 1:20 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-1409
Mailing Address - Country:US
Mailing Address - Phone:320-253-8380
Mailing Address - Fax:320-253-8419
Practice Address - Street 1:1521 NORTHWAY DR
Practice Address - Street 2:SUITE 108
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4489
Practice Address - Country:US
Practice Address - Phone:320-253-8380
Practice Address - Fax:320-253-8419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND116941223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty