Healthcare Provider Details

I. General information

NPI: 1902542608
Provider Name (Legal Business Name): COLLIN JOEL JIMES DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2022
Last Update Date: 01/16/2023
Certification Date: 01/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8427 KELWOOD AVE
BATON ROUGE LA
70806-4806
US

IV. Provider business mailing address

2550 BRENTWOOD DR
BATON ROUGE LA
70809-1745
US

V. Phone/Fax

Practice location:
  • Phone: 225-928-9838
  • Fax:
Mailing address:
  • Phone: 318-469-0025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7315
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7315
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: