Healthcare Provider Details

I. General information

NPI: 1235454950
Provider Name (Legal Business Name): EDWARD CHARLES COLLINS III DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2010
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3367 DOUGLAS RD
SOUTH BEND IN
46635-1779
US

IV. Provider business mailing address

270 E DAY RD SUITE 260
MISHAWAKA IN
46545-3444
US

V. Phone/Fax

Practice location:
  • Phone: 574-272-8823
  • Fax: 574-277-1837
Mailing address:
  • Phone: 574-272-8823
  • Fax: 574-277-1837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12012076A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: