Provider Demographics
NPI:1558338087
Name:BEARD, CHARLES THEODORE (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:THEODORE
Last Name:BEARD
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 1:1456 FULTON ST
Mailing Address - Street 2:BEDFORD STUYVESANT FAMILY HEALTH CENTER
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-2505
Mailing Address - Country:US
Mailing Address - Phone:718-636-4500
Mailing Address - Fax:347-296-8363
Practice Address - Street 1:1456 FULTON ST
Practice Address - Street 2:BEDFORD STUYVESANT FAMILY HEALTH CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-2505
Practice Address - Country:US
Practice Address - Phone:718-636-4500
Practice Address - Fax:347-296-8363
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0430061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01485652Medicaid