Provider Demographics
NPI:1639178478
Name:BRANEN, CHARLES L (DMD, PC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
Last Name:BRANEN
Suffix:
Gender:M
Credentials:DMD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 MERCANTILE DR., SUITE 150
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-2633
Mailing Address - Country:US
Mailing Address - Phone:503-636-3641
Mailing Address - Fax:503-765-5310
Practice Address - Street 1:4055 MERCANTILE DR., SUITE 150
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2633
Practice Address - Country:US
Practice Address - Phone:503-636-3641
Practice Address - Fax:503-765-5310
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2023-12-06
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
ORD72061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice