Provider Demographics
NPI:1407262827
Name:CHURCH, CHARLOTTE M (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:M
Last Name:CHURCH
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 1:416 ROOSEVELT HWY
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-5975
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:416 ROOSEVELT HWY STE 201
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446
Practice Address - Country:US
Practice Address - Phone:802-655-4614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2019-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE71471223G0001X
VT016.01338761223G0001X
VT38761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice