Basic Information
| Provider Information | |||||||||
| NPI: | 1407979107 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLIER | ||||||||
| FirstName: | EVELYN | ||||||||
| MiddleName: | WINFORD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COLLIER | ||||||||
| OtherFirstName: | EVELYN | ||||||||
| OtherMiddleName: | WINFORD | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1090 NORTHCHASE PKWY SE | ||||||||
| Address2: | STE. 290 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300676405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789045665 | ||||||||
| FaxNumber: | 6782477862 | ||||||||
| Practice Location | |||||||||
| Address1: | 2650 BEACH BLVD | ||||||||
| Address2: | STE. 31 | ||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395314517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2282731689 | ||||||||
| FaxNumber: | 2283882051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 08/23/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2892-95 | MS | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 00660217 | 05 | MS | MEDICAID |