Provider Demographics
NPI:1164551057
Name:FANA, CHARLES RICHARD JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RICHARD
Last Name:FANA
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7130 HODGSON MEMORIAL DR
Mailing Address - Street 2:STE 103
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-1526
Mailing Address - Country:US
Mailing Address - Phone:912-352-3955
Mailing Address - Fax:
Practice Address - Street 1:7130 HODGSON MEMORIAL DR
Practice Address - Street 2:STE 103
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-1526
Practice Address - Country:US
Practice Address - Phone:912-352-3955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN01166271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice