Healthcare Provider Details

I. General information

NPI: 1407825656
Provider Name (Legal Business Name): MITCHELL LYNN COLLINS D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 WESTERN AVE SUITE 204
CONWAY AR
72034-4967
US

IV. Provider business mailing address

525 WESTERN AVE SUITE 204
CONWAY AR
72034-4967
US

V. Phone/Fax

Practice location:
  • Phone: 501-336-8888
  • Fax: 501-336-8887
Mailing address:
  • Phone: 501-336-8888
  • Fax: 501-336-8887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3079
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: