Provider Demographics
NPI:1902320286
Name:KOLLATH, ANDREW JOHN
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JOHN
Last Name:KOLLATH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7270 FORESTVIEW LN N STE 250
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-5605
Mailing Address - Country:US
Mailing Address - Phone:763-424-9202
Mailing Address - Fax:
Practice Address - Street 1:7270 FORESTVIEW LN N STE 250
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369
Practice Address - Country:US
Practice Address - Phone:763-424-9202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-28
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10015491223G0001X
MND141111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice