Provider Demographics
NPI:1619359213
Name:ST. CHARLES FAMILY DENTAL
Entity Type:Organization
Organization Name:ST. CHARLES FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN-BORDES
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:301-645-6500
Mailing Address - Street 1:173 SAINT PATRICKS DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-5529
Mailing Address - Country:US
Mailing Address - Phone:301-645-6500
Mailing Address - Fax:301-632-6492
Practice Address - Street 1:173 SAINT PATRICKS DR
Practice Address - Street 2:SUITE 204
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-5529
Practice Address - Country:US
Practice Address - Phone:301-645-6500
Practice Address - Fax:301-632-6492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty