Provider Demographics
NPI:1417059148
Name:MUSTO, CHARLES JOSEPH (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOSEPH
Last Name:MUSTO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:920 WYOMING AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:FORTY FORT
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3999
Mailing Address - Country:US
Mailing Address - Phone:570-283-3611
Mailing Address - Fax:570-283-3396
Practice Address - Street 1:920 WYOMING AVE
Practice Address - Street 2:STE 104
Practice Address - City:FORTY FORT
Practice Address - State:PA
Practice Address - Zip Code:18704-3970
Practice Address - Country:US
Practice Address - Phone:570-283-3611
Practice Address - Fax:570-283-3396
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADP027522A207L00000X
PADS027522L1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA727338OtherPA BLUE SHIELD
PA808758OtherFIRST PRIORITY HEALTH BC
PA727338OtherUNITED CONCORDIA
PA808758OtherFIRST PRIORITY HEALTH BC