Healthcare Provider Details

I. General information

NPI: 1669928206
Provider Name (Legal Business Name): IAN COLLING DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 08/28/2023
Certification Date: 08/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USNMRTU IWAKUNI, BLDG 110, MCAS IWAKUNI 1 MISUMI MACHI
IWAKUNI YAMAGUCHI
7400025
JP

IV. Provider business mailing address

PSC 561 BOX 1877
FPO AP
96310-0014
US

V. Phone/Fax

Practice location:
  • Phone: 315-255-8500
  • Fax:
Mailing address:
  • Phone: 315-255-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7334
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number7334
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: