Provider Demographics
NPI:1649206707
Name:DOUGLAS, CHARMEN W (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARMEN
Middle Name:W
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 HADDONFIELD-BERLIN ROAD
Mailing Address - Street 2:SUITE#302
Mailing Address - City:GIBBSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08026
Mailing Address - Country:US
Mailing Address - Phone:856-346-8900
Mailing Address - Fax:856-346-8866
Practice Address - Street 1:146 HADDONFIELD BERLIN RD S
Practice Address - Street 2:SUITE#302
Practice Address - City:GIBBSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08026-1018
Practice Address - Country:US
Practice Address - Phone:856-346-8900
Practice Address - Fax:856-346-8866
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI017381001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice