Provider Demographics
NPI:1629646096
Name:COLLIE, AMANDA DICKERSON (DDS)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:DICKERSON
Last Name:COLLIE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 LIBBIE MILL EAST BLVD APT 508
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-2146
Mailing Address - Country:US
Mailing Address - Phone:804-955-9068
Mailing Address - Fax:
Practice Address - Street 1:1000 E BROAD ST STE 200
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219-1930
Practice Address - Country:US
Practice Address - Phone:804-828-9095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0401417563122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program