Provider Demographics
NPI:1750451555
Name:DTALEY, CHARLES RICHARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RICHARD
Last Name:DTALEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6950 NE CAMPUS WAY
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5611
Mailing Address - Country:US
Mailing Address - Phone:503-952-2164
Mailing Address - Fax:503-526-4418
Practice Address - Street 1:14495 SW ALLEN BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-4427
Practice Address - Country:US
Practice Address - Phone:503-526-0318
Practice Address - Fax:503-626-1054
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR48791223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR6783OtherOREGON HEALTH PLAN