Healthcare Provider Details

I. General information

NPI: 1740640705
Provider Name (Legal Business Name): COLLEEN BOTHELL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2016
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 S 8TH ST
YAKIMA WA
98901-3020
US

IV. Provider business mailing address

PO BOX 2605
YAKIMA WA
98907-2605
US

V. Phone/Fax

Practice location:
  • Phone: 509-454-4143
  • Fax:
Mailing address:
  • Phone: 509-454-4143
  • Fax: 509-454-4115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60732007
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: