Provider Demographics
NPI:1851834964
Name:POOLE, CHARLES PRESTON (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:PRESTON
Last Name:POOLE
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 1:3608 DALE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-0500
Mailing Address - Country:US
Mailing Address - Phone:209-577-0777
Mailing Address - Fax:209-577-0885
Practice Address - Street 1:4101 TULLY RD STE 201
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-8981
Practice Address - Country:US
Practice Address - Phone:209-577-0777
Practice Address - Fax:209-572-3845
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1003731223G0001X
SC91421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice