Provider Demographics
NPI:1790854164
Name:GAVIN, CHARLES R (DDS,PS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:GAVIN
Suffix:
Gender:M
Credentials:DDS,PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1515
Mailing Address - Street 2:
Mailing Address - City:CHELAN
Mailing Address - State:WA
Mailing Address - Zip Code:98816-1515
Mailing Address - Country:US
Mailing Address - Phone:509-682-4056
Mailing Address - Fax:509-682-4133
Practice Address - Street 1:111 CHELAN AVE
Practice Address - Street 2:
Practice Address - City:CHELAN
Practice Address - State:WA
Practice Address - Zip Code:98816
Practice Address - Country:US
Practice Address - Phone:509-682-4056
Practice Address - Fax:509-682-4133
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA48661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5526801OtherDSHS PROVIDER #