Provider Demographics
NPI:1225051899
Name:TOLBERT, CHARLES CULLEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:CULLEY
Last Name:TOLBERT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 AUDUBON WOODS
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-8883
Mailing Address - Country:US
Mailing Address - Phone:601-853-6926
Mailing Address - Fax:
Practice Address - Street 1:1500 E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-364-1294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2370-871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice