Provider Demographics
NPI:1528648045
Name:COLLINS, JACOB SHONOTA
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:SHONOTA
Last Name:COLLINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 E 30TH ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-4503
Mailing Address - Country:US
Mailing Address - Phone:505-327-4863
Mailing Address - Fax:
Practice Address - Street 1:2525 E 30TH ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-4503
Practice Address - Country:US
Practice Address - Phone:505-327-4863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM062584122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist