Provider Demographics
NPI:1689643348
Name:MEHLE, CHARLES RAYMOND JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RAYMOND
Last Name:MEHLE
Suffix:JR
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 1:310 MISSISSIPPI AVE
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-3850
Mailing Address - Country:US
Mailing Address - Phone:985-735-9811
Mailing Address - Fax:985-735-0064
Practice Address - Street 1:310 MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-3850
Practice Address - Country:US
Practice Address - Phone:985-735-9811
Practice Address - Fax:985-735-0064
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA33121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1833126Medicaid