Provider Demographics
NPI:1316383631
Name:CHARLES COLE D.D.S LLC
Entity Type:Organization
Organization Name:CHARLES COLE D.D.S LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-631-3630
Mailing Address - Street 1:1830 E PARKS HWY
Mailing Address - Street 2:SUITE A134
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654
Mailing Address - Country:US
Mailing Address - Phone:907-631-3630
Mailing Address - Fax:
Practice Address - Street 1:1830 E PARKS HWY
Practice Address - Street 2:A134
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7378
Practice Address - Country:US
Practice Address - Phone:907-631-3630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK628122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD0007Medicaid