Healthcare Provider Details

I. General information

NPI: 1871780403
Provider Name (Legal Business Name): DR. LATEDRA COLLINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2706 RYAN ST
LAKE CHARLES LA
70601-7328
US

IV. Provider business mailing address

2706 RYAN ST
LAKE CHARLES LA
70601-7328
US

V. Phone/Fax

Practice location:
  • Phone: 225-263-6780
  • Fax:
Mailing address:
  • Phone: 816-213-0937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2007021218
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5876
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: