Provider Demographics
NPI:1164546750
Name:MEAD, CHARLES REESE (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:REESE
Last Name:MEAD
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 1:624 FURGOL LN
Mailing Address - Street 2:C REESE MEAD DDS
Mailing Address - City:LAKE HAVASU
Mailing Address - State:AZ
Mailing Address - Zip Code:86406
Mailing Address - Country:US
Mailing Address - Phone:928-453-3285
Mailing Address - Fax:
Practice Address - Street 1:101 RIVERIA DR
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU
Practice Address - State:AZ
Practice Address - Zip Code:86406
Practice Address - Country:US
Practice Address - Phone:928-855-5061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice