Provider Demographics
NPI:1295013662
Name:SUTERA, CHARLES III (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:SUTERA
Suffix:III
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 1:20 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-2519
Mailing Address - Country:US
Mailing Address - Phone:978-314-8974
Mailing Address - Fax:
Practice Address - Street 1:75 3RD AVE
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-7549
Practice Address - Country:US
Practice Address - Phone:781-487-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2018-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN42071223G0001X
MADN18558531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice