Provider Demographics
NPI:1164090346
Name:COON, CHARLES (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:COON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 SOMERVILLE RD SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-5015
Mailing Address - Country:US
Mailing Address - Phone:256-355-2275
Mailing Address - Fax:
Practice Address - Street 1:701 NW MCNELLY RD STE 13
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-9160
Practice Address - Country:US
Practice Address - Phone:517-648-4503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD-0006888-C1122300000X
MO2023034426122300000X
AR4728122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist