Healthcare Provider Details

I. General information

NPI: 1740484641
Provider Name (Legal Business Name): COLLINS DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLUE HOLE RD
SANTA ROSA NM
88435-2533
US

IV. Provider business mailing address

1000 BLUE HOLE RD
SANTA ROSA NM
88435-2533
US

V. Phone/Fax

Practice location:
  • Phone: 505-718-6899
  • Fax:
Mailing address:
  • Phone: 505-718-6899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD2208
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD2469
License Number StateNM

VIII. Authorized Official

Name: DR. RAYMOND FRANK COLLINS
Title or Position: PRESIDENT
Credential: DDS
Phone: 505-718-6899