MEDICARE: GORDON WILLIAM COLLINS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5164	WA

General Provider Information

NPI Number	:	1871716647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GORDON WILLIAM COLLINS DDS

Provider Business Mailing Address
First Line	:	PO BOX 7272
Second Line	:
City	:	BONNEY LAKE
State	:	WA
Zip	:	98391-0939
Country	:	US
Telephone Number	:	253-863-5185
Fax Number	:	253-863-5185

Provider Business Practice Location Address
First Line	:	8910 184TH AVE E
Second Line	:	SUITE D
City	:	BONNEY LAKE
State	:	WA
Zip	:	98391-8531
Country	:	US
Telephone Number	:	253-863-5185
Fax Number	:	253-863-5185

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	07/08/2007

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