Provider Demographics
NPI:1629147723
Name:CRAGO, CHARLES A (DMD, MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:CRAGO
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4344 20TH AVE S
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-7436
Mailing Address - Country:US
Mailing Address - Phone:701-239-5969
Mailing Address - Fax:701-239-0034
Practice Address - Street 1:4344 20TH AVE S
Practice Address - Street 2:SUITE 2
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-7436
Practice Address - Country:US
Practice Address - Phone:701-239-5969
Practice Address - Fax:701-239-0034
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND19271223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41302Medicaid
ND1927OtherDENTAL LICENSE