Healthcare Provider Details

I. General information

NPI: 1386731230
Provider Name (Legal Business Name): GARY R COLLINS MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 SKYLINE DRIVE SUITE 1
WILMINGTON DE
19808
US

IV. Provider business mailing address

5500 SKYLINE DRIVE SUITE 1
WILMINGTON DE
19808
US

V. Phone/Fax

Practice location:
  • Phone: 302-235-3531
  • Fax: 302-239-5352
Mailing address:
  • Phone: 410-398-8642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number783
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: