Provider Demographics
NPI:1821102229
Name:DUFORT, CHARLES R (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:DUFORT
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 1:1300 ESTHER ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-2889
Mailing Address - Country:US
Mailing Address - Phone:360-693-4701
Mailing Address - Fax:360-993-5299
Practice Address - Street 1:1300 ESTHER ST
Practice Address - Street 2:SUITE 101
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-2889
Practice Address - Country:US
Practice Address - Phone:360-693-4701
Practice Address - Fax:360-993-5299
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA82331223P0700X
OR72331223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics