Provider Demographics
NPI:1730265083
Name:COLLINS FAMILY DENTAL CARE
Entity type:Organization
Organization Name:COLLINS FAMILY DENTAL CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-765-4355
Mailing Address - Street 1:P.O. BOX 1508
Mailing Address - Street 2:
Mailing Address - City:COLLINS
Mailing Address - State:MS
Mailing Address - Zip Code:39428
Mailing Address - Country:US
Mailing Address - Phone:601-765-4355
Mailing Address - Fax:601-765-4745
Practice Address - Street 1:103 S. FIR STREET
Practice Address - Street 2:
Practice Address - City:COLLINS
Practice Address - State:MS
Practice Address - Zip Code:39428
Practice Address - Country:US
Practice Address - Phone:601-765-4355
Practice Address - Fax:601-765-4745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-30
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty