Healthcare Provider Details

I. General information

NPI: 1114006020
Provider Name (Legal Business Name): KENNETH RAY COLLINS JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CARNEGIE PL SUITE 108
FAYETTEVILLE GA
30214-3905
US

IV. Provider business mailing address

100 CARNEGIE PL SUITE 108
FAYETTEVILLE GA
30214-3905
US

V. Phone/Fax

Practice location:
  • Phone: 770-461-0188
  • Fax: 770-461-0488
Mailing address:
  • Phone: 770-461-0188
  • Fax: 770-461-0488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number012476
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: