Provider Demographics
NPI:1760509566
Name:HUBLEY, CHARLES EDWIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EDWIN
Last Name:HUBLEY
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 1:2001 E 70TH ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5328
Mailing Address - Country:US
Mailing Address - Phone:318-798-1719
Mailing Address - Fax:
Practice Address - Street 1:2001 E 70TH ST
Practice Address - Street 2:SUITE 305
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5328
Practice Address - Country:US
Practice Address - Phone:318-798-1719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA37731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAD1223OtherBLUE CROSS BLUE SH. LA