Provider Demographics
NPI:1538298492
Name:DYER, CHARLES DODD (DMD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DODD
Last Name:DYER
Suffix:
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:PO BOX 2333
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39130
Mailing Address - Country:US
Mailing Address - Phone:601-856-5227
Mailing Address - Fax:601-856-9055
Practice Address - Street 1:200 KEY DRIVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110
Practice Address - Country:US
Practice Address - Phone:601-856-5227
Practice Address - Fax:601-856-9055
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS200983122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00064031Medicaid