Provider Demographics
NPI:1063506855
Name:RATHMELL, CHARLES MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MICHAEL
Last Name:RATHMELL
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 1:1221 W BEN WHITE BLVD
Mailing Address - Street 2:SUITE 212A
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-6888
Mailing Address - Country:US
Mailing Address - Phone:512-444-4400
Mailing Address - Fax:512-447-7551
Practice Address - Street 1:1221 W BEN WHITE BLVD
Practice Address - Street 2:SUITE 212A
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-6888
Practice Address - Country:US
Practice Address - Phone:512-444-4400
Practice Address - Fax:512-447-7551
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice