Healthcare Provider Details

I. General information

NPI: 1548678758
Provider Name (Legal Business Name): GRANT KOLLENBORN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 US-89, SUITE 102
JACKSON WY
83001
US

IV. Provider business mailing address

PO BOX 8888
JACKSON WY
83002-8888
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-4122
  • Fax: 307-733-4164
Mailing address:
  • Phone: 307-690-7377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6488
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: