Provider Demographics
NPI:1134415763
Name:COLLAZO, MILDRED (DDS)
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:
Last Name:COLLAZO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 LABORE RD
Mailing Address - Street 2:#320
Mailing Address - City:LITTLE CANADA
Mailing Address - State:MN
Mailing Address - Zip Code:55117-1156
Mailing Address - Country:US
Mailing Address - Phone:561-294-4796
Mailing Address - Fax:
Practice Address - Street 1:1790 7TH ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-3419
Practice Address - Country:US
Practice Address - Phone:651-735-0595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12955122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist