Provider Demographics
NPI:1326013921
Name:CASWELL, CHARISSE L (DMD)
Entity Type:Individual
Prefix:
First Name:CHARISSE
Middle Name:L
Last Name:CASWELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HANDLEY RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-2177
Mailing Address - Country:US
Mailing Address - Phone:770-632-7090
Mailing Address - Fax:770-632-7075
Practice Address - Street 1:120 HANDLEY RD
Practice Address - Street 2:SUITE 210
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-2177
Practice Address - Country:US
Practice Address - Phone:770-632-7090
Practice Address - Fax:770-632-7075
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0131631223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA773054619GMedicaid
GA773054619HMedicaid