=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154460574
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN B MCCOLLUM DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 08/27/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 SOUTH IDAHO STREET STATE BANK BUILDING
-----------------------------------------------------
City | DILLON
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-683-5125
-----------------------------------------------------
Fax | 406-683-5126
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1255
-----------------------------------------------------
City | DILLON
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59725-1255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-683-5125
-----------------------------------------------------
Fax | 406-683-5126
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN B MCCOLLUM
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 406-683-5125
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 1108
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------