Provider Demographics
NPI:1699859066
Name:DEWILD, CHARLES N (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:N
Last Name:DEWILD
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 BELLAGIO CIR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-5001
Mailing Address - Country:US
Mailing Address - Phone:407-330-3250
Mailing Address - Fax:407-330-3209
Practice Address - Street 1:205 BELLAGIO CIR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-5001
Practice Address - Country:US
Practice Address - Phone:407-330-3250
Practice Address - Fax:407-330-3209
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN148411223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery