Provider Demographics
NPI:1346353125
Name:RIDDLE, CHARLES G (DDS)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:G
Last Name:RIDDLE
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 1:10003 WEBSTER RD
Mailing Address - Street 2:
Mailing Address - City:CAMDEN ON GAULEY
Mailing Address - State:WV
Mailing Address - Zip Code:26208-7713
Mailing Address - Country:US
Mailing Address - Phone:304-226-5725
Mailing Address - Fax:304-226-3274
Practice Address - Street 1:415 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1343
Practice Address - Country:US
Practice Address - Phone:304-872-1663
Practice Address - Fax:304-872-1804
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV29601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0133133000Medicaid