Healthcare Provider Details

I. General information

NPI: 1861552937
Provider Name (Legal Business Name): MEL COLLAZO DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
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:
Title or Position:
Credential:
Phone: