Provider Demographics
NPI:1326163809
Name:DILLARD, CHARLES RANDLE JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RANDLE
Last Name:DILLARD
Suffix:JR
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 1:4330 HIGHWAY 78 E
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-8905
Mailing Address - Country:US
Mailing Address - Phone:202-295-2992
Mailing Address - Fax:205-384-1291
Practice Address - Street 1:4330 HIGHWAY 78 E
Practice Address - Street 2:SUITE 200
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-8905
Practice Address - Country:US
Practice Address - Phone:202-295-2992
Practice Address - Fax:205-384-1291
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL49171223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics