Provider Demographics
NPI:1174646194
Name:PELLETIER, CHARLES CRAIG (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:CRAIG
Last Name:PELLETIER
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 1:6552 BOLSA AVE
Mailing Address - Street 2:SUITE Q
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-2622
Mailing Address - Country:US
Mailing Address - Phone:714-897-8980
Mailing Address - Fax:714-897-6991
Practice Address - Street 1:6552 BOLSA AVE
Practice Address - Street 2:SUITE Q
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-2656
Practice Address - Country:US
Practice Address - Phone:714-897-8980
Practice Address - Fax:714-897-6991
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30271122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist