Provider Demographics
NPI:1003980103
Name:FUQUA, CHARLES KEITH (DDS)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:KEITH
Last Name:FUQUA
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 1:2444 S DETROIT AVE
Mailing Address - Street 2:C KEITH FUGUA DDS
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537
Mailing Address - Country:US
Mailing Address - Phone:419-893-8431
Mailing Address - Fax:419-893-7234
Practice Address - Street 1:2444 S DETROIT AVE
Practice Address - Street 2:C KEITH FUGUA DDS
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537
Practice Address - Country:US
Practice Address - Phone:419-893-8431
Practice Address - Fax:419-893-7234
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH142551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0227150Medicaid