Provider Demographics
NPI:1619966314
Name:TILSON, CHARLES E (DMD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:TILSON
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 1:7007 WYOMING BLVD NE
Mailing Address - Street 2:STE A4
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3987
Mailing Address - Country:US
Mailing Address - Phone:505-821-1433
Mailing Address - Fax:505-821-1442
Practice Address - Street 1:7007 WYOMING BLVD NE
Practice Address - Street 2:STE A4
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3987
Practice Address - Country:US
Practice Address - Phone:505-821-1433
Practice Address - Fax:505-821-1442
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1611122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM9179005Medicaid