Provider Demographics
NPI:1972884955
Name:COLLINS, KEVIN E (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:E
Last Name:COLLINS
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 1:475 W. 55TH ST.
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LAGRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-3566
Mailing Address - Country:US
Mailing Address - Phone:708-354-5575
Mailing Address - Fax:708-354-5504
Practice Address - Street 1:475 W. 55TH ST.
Practice Address - Street 2:SUITE 204
Practice Address - City:LAGRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-3566
Practice Address - Country:US
Practice Address - Phone:708-354-5575
Practice Address - Fax:708-354-5504
Is Sole Proprietor?:No
Enumeration Date:2011-09-02
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1914819122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist