Provider Demographics
NPI:1316125479
Name:KOLLMANN, JEFFREY ALAN (LD)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:ALAN
Last Name:KOLLMANN
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 12TH AVENUE SOUTH
Mailing Address - Street 2:NAMPA DENTURE CLINIC
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651
Mailing Address - Country:US
Mailing Address - Phone:208-467-1107
Mailing Address - Fax:
Practice Address - Street 1:1120 12TH AVENUE SOUTH
Practice Address - Street 2:NAMPA DENTURE CLINIC
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651
Practice Address - Country:US
Practice Address - Phone:208-467-1107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLD23122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist