Provider Demographics
NPI:1598923138
Name:COLLARI, RICHARD A
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:COLLARI
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 1:420 MAIN ST
Mailing Address - Street 2:5A
Mailing Address - City:WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02081
Mailing Address - Country:US
Mailing Address - Phone:508-660-2300
Mailing Address - Fax:508-850-8951
Practice Address - Street 1:420 MAIN ST
Practice Address - Street 2:5A
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081
Practice Address - Country:US
Practice Address - Phone:508-660-2300
Practice Address - Fax:508-850-8951
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10846122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist