Provider Demographics
NPI:1740484641
Name:COLLINS DENTAL
Entity type:Organization
Organization Name:COLLINS DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-718-6899
Mailing Address - Street 1:1000 BLUE HOLE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88435-2533
Mailing Address - Country:US
Mailing Address - Phone:505-718-6899
Mailing Address - Fax:
Practice Address - Street 1:1000 BLUE HOLE RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:NM
Practice Address - Zip Code:88435-2533
Practice Address - Country:US
Practice Address - Phone:505-718-6899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD24691223G0001X
NMDD22081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty