MEDICARE: DR. SAMUEL COLLINS D.M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	10616	TN

General Provider Information

NPI Number	:	1144763749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL COLLINS D.M.D

Provider Business Mailing Address
First Line	:	25 STONE RIDGE CV
Second Line	:
City	:	HUNTINGDON
State	:	TN
Zip	:	38344-1738
Country	:	US
Telephone Number	:	731-986-9484
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 DEMONBREUN ST APT 1503
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37201-2347
Country	:	US
Telephone Number	:	865-243-7315
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2016
Last Update Date	:	10/25/2018

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