Provider Demographics
NPI:1962420067
Name:COLCLASURE, RAY E (DDS)
Entity type:Individual
Prefix:DR
First Name:RAY
Middle Name:E
Last Name:COLCLASURE
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 1:550 W 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-7134
Mailing Address - Country:US
Mailing Address - Phone:870-536-4567
Mailing Address - Fax:870-536-3580
Practice Address - Street 1:550 W 46TH AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-7134
Practice Address - Country:US
Practice Address - Phone:870-536-4567
Practice Address - Fax:870-536-3580
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR20471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR98892OtherUNITED CONCORDIA PROVIDER
AR58101OtherAR BLUE CROSS BLUE SHEILD