Provider Demographics
NPI:1922189109
Name:CHARLES, BRIAN WILLIAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:WILLIAM
Last Name:CHARLES
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 1:1003 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-3822
Mailing Address - Country:US
Mailing Address - Phone:208-634-7653
Mailing Address - Fax:208-634-4568
Practice Address - Street 1:1003 N 3RD ST
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-3822
Practice Address - Country:US
Practice Address - Phone:208-634-7653
Practice Address - Fax:208-634-4568
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-17961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice