Provider Demographics
NPI:1407130040
Name:COLLAZOS ESCALANTE, LUIS MIGUEL (DDS)
Entity type:Individual
Prefix:DR
First Name:LUIS MIGUEL
Middle Name:
Last Name:COLLAZOS ESCALANTE
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 1:15565 TUPPER ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-3246
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 H ST STE C
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93304-2910
Practice Address - Country:US
Practice Address - Phone:661-327-2155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA609231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice