Healthcare Provider Details

I. General information

NPI: 1093061202
Provider Name (Legal Business Name): THERESA M. COLLINS D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 08/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2058 S DOBSON RD STE 12
MESA AZ
85202-6454
US

IV. Provider business mailing address

2058 S DOBSON RD STE 12
MESA AZ
85202-6454
US

V. Phone/Fax

Practice location:
  • Phone: 503-267-7559
  • Fax:
Mailing address:
  • Phone: 503-267-7559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD009063
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD9756
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: