Provider Demographics
NPI:1548245954
Name:ANDERS, CHARLES W (DMD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:W
Last Name:ANDERS
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 1:1244 5TH ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-2630
Mailing Address - Country:US
Mailing Address - Phone:423-784-3587
Mailing Address - Fax:423-784-7730
Practice Address - Street 1:1244 5TH ST
Practice Address - Street 2:SUITE 4
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762-2630
Practice Address - Country:US
Practice Address - Phone:423-784-3587
Practice Address - Fax:423-784-7730
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60055258Medicaid