Provider Demographics
NPI:1891864591
Name:CORDOVA, CHARLES RICHARD (DDS)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:RICHARD
Last Name:CORDOVA
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 1:3714 GREAT LAND ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603
Mailing Address - Country:US
Mailing Address - Phone:907-235-6106
Mailing Address - Fax:907-235-6107
Practice Address - Street 1:3714 GREAT LAND ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603
Practice Address - Country:US
Practice Address - Phone:907-235-6106
Practice Address - Fax:907-235-6107
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA6911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice