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Collinsville Family Dental, PLLC

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Company Details

Name: Collinsville Family Dental, PLLC
Jurisdiction: MISSISSIPPI
Business Type: Limited Liability Company
Status: Dissolved
Effective Date: 15 Sep 2010 (15 years ago)
Business ID: 971737
State of Incorporation: MISSISSIPPI

Agent

Name Role Address
Martin, W. Brock Agent 9128 Mae Crooker Circle, Lauderdale, MS 39335

Member

Name Role Address
W. Brock Martin Member 9128 Mae Crooker Circle, Lauderdale, MS 39335
Robert S. Justus Member 9128 Mae Crooker Circle, Lauderdale, MS 39335

National Provider Identifier

NPI Number:
1770883688

Authorized Person:

Name:
DR. BROCK MARTIN
Role:
DENTIST/OWNER
Phone:

Taxonomy:

Selected Taxonomy:
122300000X - Dentist
Is Primary:
Yes

Contacts:

Filings

Type Status Filed Date Description
Failure to File AR Filed 2011-12-05 Failure to File AR
Formation Form Filed 2010-09-15 Formation

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Date of last update: 09 May 2025

Sources: Company Profile on Mississippi Secretary of State Website