Provider Demographics
NPI:1376112946
Name:CERVELLERA, CHARLINE JOSEPHINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLINE
Middle Name:JOSEPHINE
Last Name:CERVELLERA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 HAWTHORNE PL APT 15F
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2330
Mailing Address - Country:US
Mailing Address - Phone:424-535-6297
Mailing Address - Fax:
Practice Address - Street 1:1133 W POPLAR AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-5839
Practice Address - Country:US
Practice Address - Phone:877-960-3426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108382122300000X
MADL14790122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist