Provider Demographics
NPI:1750481933
Name:COLLURA, GRACE MARY (DMD)
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:MARY
Last Name:COLLURA
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 1:77 MASSACHUSETTS AVE
Mailing Address - Street 2:E23-530
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-4301
Mailing Address - Country:US
Mailing Address - Phone:617-253-1501
Mailing Address - Fax:
Practice Address - Street 1:77 MASSACHUSETTS AVE
Practice Address - Street 2:E23-530
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-4301
Practice Address - Country:US
Practice Address - Phone:617-253-1501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA166051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX07290OtherBLUE CROSS BLUE SHIELD