Provider Demographics
NPI:1689871071
Name:STROUD, CHARLES DOUGLAS (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DOUGLAS
Last Name:STROUD
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 1:285 RANGER DR
Mailing Address - Street 2:
Mailing Address - City:ELLENBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28040-5716
Mailing Address - Country:US
Mailing Address - Phone:704-434-4994
Mailing Address - Fax:
Practice Address - Street 1:416 W WARREN ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-5330
Practice Address - Country:US
Practice Address - Phone:704-482-3281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC 3230122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist