Provider Demographics
NPI:1417149360
Name:WORTHAM, CHARLES F (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:F
Last Name:WORTHAM
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 1:10364 LEADBETTER RD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23005-3420
Mailing Address - Country:US
Mailing Address - Phone:804-550-2148
Mailing Address - Fax:
Practice Address - Street 1:10364 LEADBETTER RD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:VA
Practice Address - Zip Code:23005-3420
Practice Address - Country:US
Practice Address - Phone:804-550-2148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010052191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice