Provider Demographics
NPI:1609976737
Name:COLLINS, KEITH WALTER (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:WALTER
Last Name:COLLINS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8615 NE HAZEL DELL AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-8017
Mailing Address - Country:US
Mailing Address - Phone:360-574-7477
Mailing Address - Fax:
Practice Address - Street 1:8615 NE HAZEL DELL AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8017
Practice Address - Country:US
Practice Address - Phone:360-574-7477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5238122300000X
OR5411122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist