Provider Demographics
NPI:1437198397
Name:ISELBORN, CHARLES ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ANTHONY
Last Name:ISELBORN
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 1:149 BRIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2312
Mailing Address - Country:US
Mailing Address - Phone:207-774-0546
Mailing Address - Fax:
Practice Address - Street 1:149 BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2312
Practice Address - Country:US
Practice Address - Phone:207-774-0546
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME3136122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME3136OtherDENTAL LICENSE NUMBER