Healthcare Provider Details

I. General information

NPI: 1629646096
Provider Name (Legal Business Name): AMANDA DICKERSON COLLIE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E BROAD ST STE 200
RICHMOND VA
23219-1930
US

IV. Provider business mailing address

5001 LIBBIE MILL EAST BLVD APT 508
RICHMOND VA
23230-2146
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-9095
  • Fax:
Mailing address:
  • Phone: 804-955-9068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401417563
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: