Provider Demographics
NPI:1831306752
Name:COLLINS, BRENT PATRICK (DDS, MS)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:PATRICK
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 1:518 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4712
Mailing Address - Country:US
Mailing Address - Phone:865-981-8800
Mailing Address - Fax:865-981-1393
Practice Address - Street 1:518 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-4712
Practice Address - Country:US
Practice Address - Phone:865-981-8800
Practice Address - Fax:865-981-1393
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000070191223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics