Provider Demographics
NPI:1295289478
Name:MCCOLLUM, DAVID (DMD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MCCOLLUM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3823 ROSWELL RD
Mailing Address - Street 2:#205
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-6278
Mailing Address - Country:US
Mailing Address - Phone:770-973-9275
Mailing Address - Fax:
Practice Address - Street 1:3823 ROSWELL RD
Practice Address - Street 2:#205
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-6278
Practice Address - Country:US
Practice Address - Phone:770-973-9275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0152551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice