Provider Demographics
NPI:1528680451
Name:CHAVOUS, COLLIN JACKSON (DMD)
Entity type:Individual
Prefix:DR
First Name:COLLIN
Middle Name:JACKSON
Last Name:CHAVOUS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5727 FRENCH CREEK CT
Mailing Address - Street 2:
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-5203
Mailing Address - Country:US
Mailing Address - Phone:864-901-7297
Mailing Address - Fax:
Practice Address - Street 1:657 TAMIAMI TRL S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-3237
Practice Address - Country:US
Practice Address - Phone:941-488-7230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-14
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN26407122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program