Provider Demographics
NPI:1346473550
Name:DREW, CHARLES BUCHANAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BUCHANAN
Last Name:DREW
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:BUCK
Other - Middle Name:
Other - Last Name:DREW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 899
Mailing Address - Street 2:2100 B WARM SPRINGS ROAD
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-0899
Mailing Address - Country:US
Mailing Address - Phone:208-726-7897
Mailing Address - Fax:
Practice Address - Street 1:1010 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2045
Practice Address - Country:US
Practice Address - Phone:208-678-5597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD- 1701122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist