MEDICARE: DR. SAMUEL DEON COLLINS DDS

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	28595	TX
2	122300000X	Dentist	28595	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5620	OTHER	TX	MCNA

General Provider Information

NPI Number	:	1447294996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL DEON COLLINS DDS

Provider Business Mailing Address
First Line	:	19404 MORRIS AVE
Second Line	:
City	:	MANVEL
State	:	TX
Zip	:	77578-3702
Country	:	US
Telephone Number	:	404-370-2510
Fax Number	:

Provider Business Practice Location Address
First Line	:	19404 MORRIS AVE
Second Line	:
City	:	MANVEL
State	:	TX
Zip	:	77578
Country	:	US
Telephone Number	:	404-370-2510
Fax Number	:

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

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	06/06/2023

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