Provider Demographics
NPI:1104219492
Name:BROWN, CHARLENE
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 PEACHTREE RD NE STE H
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3020
Mailing Address - Country:US
Mailing Address - Phone:404-594-2650
Mailing Address - Fax:
Practice Address - Street 1:4060 PEACHTREE RD NE STE H
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-3020
Practice Address - Country:US
Practice Address - Phone:404-549-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-10
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0151001223G0001X
LA65901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice