Provider Demographics
NPI:1467477315
Name:ROSSON, CHARLES CALVERT III (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:CALVERT
Last Name:ROSSON
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 NE MULTNOMAH ST
Mailing Address - Street 2:STE 100
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2031
Mailing Address - Country:US
Mailing Address - Phone:503-813-4947
Mailing Address - Fax:503-813-3103
Practice Address - Street 1:5025 SE 28TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-4445
Practice Address - Country:US
Practice Address - Phone:503-238-4418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD63051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice