Provider Demographics
NPI:1215949391
Name:COLLINSWORTH, KLAUS DIETER (DDS)
Entity type:Individual
Prefix:DR
First Name:KLAUS
Middle Name:DIETER
Last Name:COLLINSWORTH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8601 VILLAGE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-5509
Mailing Address - Country:US
Mailing Address - Phone:210-657-6453
Mailing Address - Fax:
Practice Address - Street 1:8601 VILLAGE DR STE 201
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5509
Practice Address - Country:US
Practice Address - Phone:210-657-6453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX 149131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX786458OtherUNITED CONCORDIA
TXTX 14913OtherBLUE CROSS BLUE SHIELD