Provider Demographics
NPI:1770883688
Name:COLLINSVILLE FAMILY DENTAL
Entity type:Organization
Organization Name:COLLINSVILLE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-482-5701
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39325-0459
Mailing Address - Country:US
Mailing Address - Phone:601-626-7555
Mailing Address - Fax:
Practice Address - Street 1:9171 A
Practice Address - Street 2:OLD HWY 19N
Practice Address - City:COLLINSVILLE
Practice Address - State:MS
Practice Address - Zip Code:39325
Practice Address - Country:US
Practice Address - Phone:601-626-7555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3396-06122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty