Provider Demographics
NPI:1598850828
Name:STODDARD, CHARLES DAVID
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DAVID
Last Name:STODDARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 E 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:GULF SHORES
Mailing Address - State:AL
Mailing Address - Zip Code:36542-3193
Mailing Address - Country:US
Mailing Address - Phone:251-948-9313
Mailing Address - Fax:251-948-8383
Practice Address - Street 1:313 E 22ND AVE
Practice Address - Street 2:
Practice Address - City:GULF SHORES
Practice Address - State:AL
Practice Address - Zip Code:36542-3193
Practice Address - Country:US
Practice Address - Phone:251-948-9313
Practice Address - Fax:251-948-8383
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3129122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009924875Medicaid
AL51515558OtherBC/BS OF ALABAMA