Healthcare Provider Details

I. General information

NPI: 1386639540
Provider Name (Legal Business Name): CHRISTOPHER MICHAEL COLLIER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 MDG/SGGD 383 MAYNARD ST.
POPE AFB NC
28308
US

IV. Provider business mailing address

436 SHAWCROFT RD
FAYETTEVILLE NC
28311-2945
US

V. Phone/Fax

Practice location:
  • Phone: 919-394-2283
  • Fax: 919-394-1194
Mailing address:
  • Phone: 910-394-2283
  • Fax: 910-394-1194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2901011785
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: