Healthcare Provider Details

I. General information

NPI: 1780990317
Provider Name (Legal Business Name): ANDREA COLLAZOS ALICEA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2010
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HQ, US ARMY MEDICAL DEPARTMENT ACTIVITY BAVARIA UNIT 28037
APO AE
09112-8037
US

IV. Provider business mailing address

1811 ARMY BLVD
JBSA FT SAM HOUSTON TX
78234-2686
US

V. Phone/Fax

Practice location:
  • Phone: 315-590-3584
  • Fax:
Mailing address:
  • Phone: 210-221-0826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10263
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: