MEDICARE: DR. KEVIN MARK COLINA DMD

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	122300000X	Dentist	0401411208	VA

General Provider Information

NPI Number	:	1760528384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN MARK COLINA DMD

Provider Business Mailing Address
First Line	:	2970 PRINCE WILLIAM PKWY
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22192-4145
Country	:	US
Telephone Number	:	703-583-7720
Fax Number	:

Provider Business Practice Location Address
First Line	:	2970 PRINCE WILLIAM PKWY
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22192-4145
Country	:	US
Telephone Number	:	703-583-7720
Fax Number	:

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

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	08/09/2012

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