Provider Demographics
NPI:1962830232
Name:MCCOLLUM, JOHN B (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:MCCOLLUM
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:P.O. BOX 1255
Mailing Address - Street 2:110 S.
Mailing Address - City:DILLON
Mailing Address - State:MT
Mailing Address - Zip Code:59725
Mailing Address - Country:US
Mailing Address - Phone:406-683-5125
Mailing Address - Fax:406-683-5126
Practice Address - Street 1:110 S. IDAHO STREET
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:MT
Practice Address - Zip Code:59725
Practice Address - Country:US
Practice Address - Phone:406-683-5125
Practice Address - Fax:406-683-5126
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1108122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0132587Medicaid