Provider Demographics
NPI:1861577561
Name:COLLINS, GORDON BLAKE (DMD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:BLAKE
Last Name:COLLINS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 LANEY WALKER BLVD
Mailing Address - Street 2:RICHMOND COUNTY HEALTH DEPT
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901
Mailing Address - Country:US
Mailing Address - Phone:706-721-5891
Mailing Address - Fax:706-721-5898
Practice Address - Street 1:950 LANEY WALKER BLVD
Practice Address - Street 2:RICHMOND COUNTY HEALTH DEPT
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901
Practice Address - Country:US
Practice Address - Phone:706-721-5891
Practice Address - Fax:706-721-5898
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN011479122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9184628OtherDORAL