Provider Demographics
NPI:1285657510
Name:MACON, CHARLES RANDALL (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:RANDALL
Last Name:MACON
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 1:7200 STONEHENGE DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-1620
Mailing Address - Country:US
Mailing Address - Phone:919-848-1882
Mailing Address - Fax:
Practice Address - Street 1:7200 STONEHENGE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-1620
Practice Address - Country:US
Practice Address - Phone:919-848-1882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC60581223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics