Provider Demographics
NPI:1831382233
Name:COLLIGAN, JEFFREY ALAN (DMD, MSD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALAN
Last Name:COLLIGAN
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 S BELLWOOD DR STE C
Mailing Address - Street 2:
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024-2086
Mailing Address - Country:US
Mailing Address - Phone:618-258-1244
Mailing Address - Fax:
Practice Address - Street 1:160 S BELLWOOD DR STE C
Practice Address - Street 2:
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-2086
Practice Address - Country:US
Practice Address - Phone:618-258-1244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU64959Medicare UPIN