Provider Demographics
NPI:1619199841
Name:R. CHARLIE AND UTE J COLLINS DDS, PLLC
Entity Type:Organization
Organization Name:R. CHARLIE AND UTE J COLLINS DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:UTE
Authorized Official - Middle Name:J
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-424-5650
Mailing Address - Street 1:1210 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-2425
Mailing Address - Country:US
Mailing Address - Phone:360-424-5650
Mailing Address - Fax:360-424-9672
Practice Address - Street 1:1210 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-2425
Practice Address - Country:US
Practice Address - Phone:360-424-5650
Practice Address - Fax:360-424-9672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA10103OtherWA STATE LICENSE
WA5050042Medicaid
WA$$$$$$$$$OtherSSN
WA1235192907OtherINDIVIDUAL NPI
WA1863209OtherUNITED CONCORDIA ID
WA5050471Medicaid
WA602 548 356OtherUBI
WA602 548 356OtherUBI
WA574642636OtherSSN