Provider Demographics
NPI:1710300595
Name:R. CHARLIE COLLINS AND UTE J. COLLINS
Entity Type:Organization
Organization Name:R. CHARLIE COLLINS AND UTE J. COLLINS
Other - Org Name:ROOSEVELT DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:CHARLIE
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-293-5311
Mailing Address - Street 1:1220 22ND ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-2582
Mailing Address - Country:US
Mailing Address - Phone:360-293-5311
Mailing Address - Fax:360-293-5114
Practice Address - Street 1:1220 22ND ST
Practice Address - Street 2:SUITE C
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-2582
Practice Address - Country:US
Practice Address - Phone:360-293-5311
Practice Address - Fax:360-293-5114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010086122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty