Provider Demographics
NPI:1003336249
Name:ABRAHAM, CHARLES G (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:G
Last Name:ABRAHAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 DENTAL SCIENCE BLDG S
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1001
Mailing Address - Country:US
Mailing Address - Phone:319-335-7440
Mailing Address - Fax:319-335-7451
Practice Address - Street 1:550 UNIVERSITY BLVD # UH3195
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:317-274-8300
Practice Address - Fax:317-274-8300
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA093971223G0001X
INLDR1802021223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice