Provider Demographics
NPI:1467449892
Name:MATTINGLY, CHARLES F (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:F
Last Name:MATTINGLY
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 1:211 W BRIARWOOD LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-1607
Mailing Address - Country:US
Mailing Address - Phone:573-445-7298
Mailing Address - Fax:
Practice Address - Street 1:409 VANDIVER DR
Practice Address - Street 2:BLDG 3 SUITE 102
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65202-3754
Practice Address - Country:US
Practice Address - Phone:573-499-1699
Practice Address - Fax:573-442-7897
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO141781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice