Provider Demographics
NPI:1912073768
Name:KEVIN E COLLINS DDS PC
Entity Type:Organization
Organization Name:KEVIN E COLLINS DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-354-5575
Mailing Address - Street 1:475 W 55TH STREET
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LAGRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-3566
Mailing Address - Country:US
Mailing Address - Phone:708-354-5575
Mailing Address - Fax:708-354-5504
Practice Address - Street 1:475 W 55TH STREET
Practice Address - Street 2:SUITE 204
Practice Address - City:LAGRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-3566
Practice Address - Country:US
Practice Address - Phone:708-354-5575
Practice Address - Fax:708-354-5504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1914819122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty