Provider Demographics
NPI:1003021908
Name:ROBERTS, CHARLES WAITSEL IV (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WAITSEL
Last Name:ROBERTS
Suffix:IV
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:142 PROFESSIONAL PARK DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5537
Mailing Address - Country:US
Mailing Address - Phone:704-664-5437
Mailing Address - Fax:704-663-7912
Practice Address - Street 1:142 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5537
Practice Address - Country:US
Practice Address - Phone:704-664-5437
Practice Address - Fax:704-663-7912
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC70231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902375Medicaid