Provider Demographics
NPI:1912279803
Name:CHARTER COLLEGE LLC
Entity Type:Organization
Organization Name:CHARTER COLLEGE LLC
Other - Org Name:CHARTER COLLEGE DENTAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-737-7403
Mailing Address - Street 1:750 SANDHILL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-4943
Mailing Address - Country:US
Mailing Address - Phone:775-849-9900
Mailing Address - Fax:775-284-9905
Practice Address - Street 1:410 W BAKERVIEW RD STE 112
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-8184
Practice Address - Country:US
Practice Address - Phone:360-647-5000
Practice Address - Fax:360-647-5002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00009350261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental