Provider Demographics
NPI:1942499249
Name:ENNIS, CHARLES TERRY (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:TERRY
Last Name:ENNIS
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 1:8 LINDSAY CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-1909
Mailing Address - Country:US
Mailing Address - Phone:706-569-1575
Mailing Address - Fax:706-568-1359
Practice Address - Street 1:8 LINDSAY CT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-1909
Practice Address - Country:US
Practice Address - Phone:706-569-1575
Practice Address - Fax:706-568-1359
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0102151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice