Healthcare Provider Details

I. General information

NPI: 1710119136
Provider Name (Legal Business Name): MEL COLLAZO, DDS, MS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2009
Last Update Date: 08/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11811 HINSON RD STE 100
LITTLE ROCK AR
72212-3472
US

IV. Provider business mailing address

11811 HINSON RD STE 100
LITTLE ROCK AR
72212-3472
US

V. Phone/Fax

Practice location:
  • Phone: 501-221-0004
  • Fax: 501-219-0300
Mailing address:
  • Phone: 501-221-0004
  • Fax: 501-219-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2749
License Number StateAR

VIII. Authorized Official

Name: SHERI COLLAZO
Title or Position: BUSINESS MANAGER
Credential:
Phone: 501-221-0004