Provider Demographics
NPI:1225156102
Name:ROSS, CHARLES ALBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALBERT
Last Name:ROSS
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 1:3706 MERCER UNIVERSITY DRIVE
Mailing Address - Street 2:SUITE 7 MISSION SQUARE
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204
Mailing Address - Country:US
Mailing Address - Phone:478-474-2557
Mailing Address - Fax:478-474-3120
Practice Address - Street 1:3706 MERCER UNIVERSITY DRIVE
Practice Address - Street 2:SUITE 7 MISSION SQUARE
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204
Practice Address - Country:US
Practice Address - Phone:478-474-2557
Practice Address - Fax:478-474-3120
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA88001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice