Healthcare Provider Details

I. General information

NPI: 1336320621
Provider Name (Legal Business Name): COLLINS ORAL & MAXILLOFACIAL SURGERY, PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2007
Last Update Date: 02/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 W 7TH AVE
SPOKANE WA
99204-2504
US

IV. Provider business mailing address

322 W 7TH AVE
SPOKANE WA
99204-2504
US

V. Phone/Fax

Practice location:
  • Phone: 509-624-2202
  • Fax:
Mailing address:
  • Phone: 509-624-2202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KRISTIN HUMPHREY
Title or Position: OFFICE MANAGER
Credential:
Phone: 509-624-2204