Provider Demographics
NPI:1942648704
Name:RADER, CHARLES EUGENE (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EUGENE
Last Name:RADER
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 1:507 E BRAZOS ST
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-5261
Mailing Address - Country:US
Mailing Address - Phone:361-576-5155
Mailing Address - Fax:361-576-9228
Practice Address - Street 1:507 E BRAZOS ST
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-5261
Practice Address - Country:US
Practice Address - Phone:361-576-5155
Practice Address - Fax:361-576-9228
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116761223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics