Provider Demographics
NPI:1114050986
Name:HAMMOND, CHARLES R (DDS,MAGD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:HAMMOND
Suffix:
Gender:M
Credentials:DDS,MAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-5120
Mailing Address - Country:US
Mailing Address - Phone:903-561-5610
Mailing Address - Fax:903-509-9267
Practice Address - Street 1:120 E HERITAGE DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5120
Practice Address - Country:US
Practice Address - Phone:903-561-5610
Practice Address - Fax:903-509-9267
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice