Provider Demographics
NPI:1366738205
Name:MARK A.COLLINS
Entity type:Organization
Organization Name:MARK A.COLLINS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:423-566-8248
Mailing Address - Street 1:3088 APPALACHIAN HWY STE 2
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757-2526
Mailing Address - Country:US
Mailing Address - Phone:423-566-8248
Mailing Address - Fax:423-566-8247
Practice Address - Street 1:3088 APPALACHIAN HWY STE 2
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TN
Practice Address - Zip Code:37757-2526
Practice Address - Country:US
Practice Address - Phone:423-566-8248
Practice Address - Fax:423-566-8247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0000008223122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty