Provider Demographics
NPI:1922612209
Name:EDMINSTEN, COLLIN LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:COLLIN
Middle Name:LEE
Last Name:EDMINSTEN
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 1:706 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-3814
Mailing Address - Country:US
Mailing Address - Phone:505-504-5323
Mailing Address - Fax:
Practice Address - Street 1:612 N CANYON ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-5842
Practice Address - Country:US
Practice Address - Phone:157-588-7759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD53251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice