Provider Demographics
NPI:1174783369
Name:CHARLES D MCNUTT DDS PA
Entity type:Organization
Organization Name:CHARLES D MCNUTT DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:MCNUTT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-741-2323
Mailing Address - Street 1:3501 NW 84TH AVE
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-6607
Mailing Address - Country:US
Mailing Address - Phone:954-741-2323
Mailing Address - Fax:954-749-3606
Practice Address - Street 1:3501 NW 84TH AVE
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-6607
Practice Address - Country:US
Practice Address - Phone:954-741-2323
Practice Address - Fax:954-749-3606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5807122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL074253800Medicaid