Provider Demographics
NPI:1184389603
Name:BRICK CITY DENTAL LLC
Entity type:Organization
Organization Name:BRICK CITY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLLATH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-790-4438
Mailing Address - Street 1:3612 S CLARK ST
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-4104
Mailing Address - Country:US
Mailing Address - Phone:573-581-4352
Mailing Address - Fax:
Practice Address - Street 1:3612 S CLARK ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-4104
Practice Address - Country:US
Practice Address - Phone:573-581-4352
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental