Provider Demographics
NPI:1821356619
Name:CHARLES DELAINE D.M.D., PLLC
Entity Type:Organization
Organization Name:CHARLES DELAINE D.M.D., PLLC
Other - Org Name:DELAINE DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:DELAINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-693-0911
Mailing Address - Street 1:520 S ALLEN RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:FLAT ROCK
Mailing Address - State:NC
Mailing Address - Zip Code:28731-9450
Mailing Address - Country:US
Mailing Address - Phone:828-693-0911
Mailing Address - Fax:828-693-9529
Practice Address - Street 1:520 S ALLEN RD
Practice Address - Street 2:SUITE 4
Practice Address - City:FLAT ROCK
Practice Address - State:NC
Practice Address - Zip Code:28731-9450
Practice Address - Country:US
Practice Address - Phone:828-693-0911
Practice Address - Fax:828-693-9529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-30
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8328261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910127Medicaid