Provider Demographics
NPI:1801010632
Name:COLLIS, RICHARD J (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:COLLIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 PACIFIC COAST HIGHWAY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-2735
Mailing Address - Country:US
Mailing Address - Phone:310-374-8901
Mailing Address - Fax:310-376-3443
Practice Address - Street 1:2401 PACIFIC COAST HIGHWAY
Practice Address - Street 2:SUITE 205
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-2735
Practice Address - Country:US
Practice Address - Phone:310-374-8901
Practice Address - Fax:310-376-3443
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA211061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice