Provider Demographics
NPI:1811208424
Name:COLLINS, GRANT CONRAD (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:CONRAD
Last Name:COLLINS
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2946 JEREMIAH LN NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-4445
Mailing Address - Country:US
Mailing Address - Phone:507-258-5400
Mailing Address - Fax:
Practice Address - Street 1:2946 JEREMIAH LN NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-4445
Practice Address - Country:US
Practice Address - Phone:507-258-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND128221223X0400X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN190001062Medicare PIN