Provider Demographics
NPI:1740772110
Name:COLLINSWORTH, MARK (RDH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:COLLINSWORTH
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601B W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-2119
Mailing Address - Country:US
Mailing Address - Phone:315-787-8151
Mailing Address - Fax:
Practice Address - Street 1:160 MAIN ST
Practice Address - Street 2:
Practice Address - City:PENN YAN
Practice Address - State:NY
Practice Address - Zip Code:14527-1204
Practice Address - Country:US
Practice Address - Phone:315-531-9102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017629124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist