Healthcare Provider Details

I. General information

NPI: 1922552520
Provider Name (Legal Business Name): COLLIN WALSH ENFINGER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2016
Last Update Date: 06/22/2020
Certification Date: 06/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653-1 W 8TH ST
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

653-1 W 8TH ST
JACKSONVILLE FL
32209-6511
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-3662
  • Fax:
Mailing address:
  • Phone: 904-244-3662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberDRPM2150
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: