Healthcare Provider Details

I. General information

NPI: 1023019254
Provider Name (Legal Business Name): JOHN R COLLINS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 W SEVIER AVE SUITE 220
KINGSPORT TN
37660-3799
US

IV. Provider business mailing address

117 W SEVIER AVE SUITE 220
KINGSPORT TN
37660-3799
US

V. Phone/Fax

Practice location:
  • Phone: 423-224-3200
  • Fax: 423-224-3208
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS4121
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: