Provider Demographics
NPI:1629489315
Name:VANSICKLEN, CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:VANSICKLEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 JOHN WESLEY GILBERT DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0001
Mailing Address - Country:US
Mailing Address - Phone:706-721-4025
Mailing Address - Fax:
Practice Address - Street 1:8619 EMANUEL WAY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95212-1423
Practice Address - Country:US
Practice Address - Phone:209-931-7931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program