Provider Demographics
NPI:1760096085
Name:COLLINS, JERRY LEE JR
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:LEE
Last Name:COLLINS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5205 E CORTLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-9362
Mailing Address - Country:US
Mailing Address - Phone:520-230-6360
Mailing Address - Fax:
Practice Address - Street 1:5205 E CORTLAND BLVD
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-9362
Practice Address - Country:US
Practice Address - Phone:520-230-6360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist