Provider Demographics
NPI:1922173632
Name:DORMAN, CHARLES WILLIAM JR (DDS MS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILLIAM
Last Name:DORMAN
Suffix:JR
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4637 QUAIL LAKES DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5258
Mailing Address - Country:US
Mailing Address - Phone:209-235-7207
Mailing Address - Fax:209-235-7210
Practice Address - Street 1:4637 QUAIL LAKES DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5258
Practice Address - Country:US
Practice Address - Phone:209-235-7207
Practice Address - Fax:209-235-7210
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA223391223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22339OtherCA. DENTAL LICENSE NUMBER