Provider Demographics
NPI:1093803231
Name:HARRELL, CHARLES J JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:HARRELL
Suffix:JR
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 1:139 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-2331
Mailing Address - Country:US
Mailing Address - Phone:601-584-9481
Mailing Address - Fax:601-544-5161
Practice Address - Street 1:139 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-2331
Practice Address - Country:US
Practice Address - Phone:601-584-9481
Practice Address - Fax:601-544-5161
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2549-901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice