=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740584374
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLLINS DENTAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2010
-----------------------------------------------------
Last Update Date | 12/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3808 FRONT ST
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-3020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-295-2202
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3808 FRONT ST
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-3020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-295-2202
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. TIMOTHY NEAL COLLINS
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 619-295-2202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 41005
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------