Provider Demographics
NPI:1134501141
Name:POBLENZ, CHARLES A (DMD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:POBLENZ
Suffix:
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 1:3647 HENDRICKS AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5360
Mailing Address - Country:US
Mailing Address - Phone:904-396-4091
Mailing Address - Fax:904-396-9091
Practice Address - Street 1:3647 HENDRICKS AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5360
Practice Address - Country:US
Practice Address - Phone:904-396-4091
Practice Address - Fax:904-396-9091
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 213621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice