Provider Demographics
NPI:1578198552
Name:CHARLES WOHLWEND DDSPC
Entity Type:Organization
Organization Name:CHARLES WOHLWEND DDSPC
Other - Org Name:EAGLERIDGE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:WOHLWEND
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-542-1212
Mailing Address - Street 1:104 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:WALSENBURG
Mailing Address - State:CO
Mailing Address - Zip Code:81089-2020
Mailing Address - Country:US
Mailing Address - Phone:719-738-2544
Mailing Address - Fax:719-738-3747
Practice Address - Street 1:104 E 6TH ST
Practice Address - Street 2:
Practice Address - City:WALSENBURG
Practice Address - State:CO
Practice Address - Zip Code:81089-2020
Practice Address - Country:US
Practice Address - Phone:719-738-2544
Practice Address - Fax:719-738-3747
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHARLES WOHLWEND DDSPC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-10
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO20Medicaid
CO30Medicaid