Healthcare Provider Details

I. General information

NPI: 1013928639
Provider Name (Legal Business Name): TIMOTHY R COLLINS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 02/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 LAKEWAY DR
GEORGETOWN TX
78628-4213
US

IV. Provider business mailing address

800 LAKEWAY DR
GEORGETOWN TX
78628-4213
US

V. Phone/Fax

Practice location:
  • Phone: 512-863-6113
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number25170
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: