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General NPI Number Information
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NPI Number | 1750556932
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Entity Type | Organization
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Legal Business Name | FORT MOHAVE DENTAL CARE PLLC
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Dates
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Enumeration Date | 04/28/2008
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Last Update Date | 03/27/2012
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Provider Practice Location Address
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Address Line | 1501 E CAMP MOHAVE RD # 1
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City | FORT MOHAVE
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State | AZ
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Zip | 86426-9406
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Country | US
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Telephone | 928-758-8887
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Fax |
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Provider Business Mailing Address
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Address Line | 1501 E CAMP MOHAVE RD # 1
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City | FORT MOHAVE
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State | AZ
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Zip | 86426-9406
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Country | US
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Telephone | 928-758-8887
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARK ALAN COLLINS
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Credential | DDS
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Telephone | 928-758-8887
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 4792
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License Number State | AZ
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