Provider Demographics
NPI:1124000393
Name:KHOURY, CHARLES PIERRE
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PIERRE
Last Name:KHOURY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 DARTMOUTH WOODS DRIVE
Mailing Address - Street 2:
Mailing Address - City:DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747
Mailing Address - Country:US
Mailing Address - Phone:508-997-7776
Mailing Address - Fax:
Practice Address - Street 1:404 HUTTLESTON AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719-5630
Practice Address - Country:US
Practice Address - Phone:508-997-7776
Practice Address - Fax:508-997-0776
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA200151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX12286OtherBCBS OF MA