Provider Demographics
NPI:1952641524
Name:BARRETT JR, CHARLES BERTRAND (DMD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BERTRAND
Last Name:BARRETT JR
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 1:1504 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40208-1711
Mailing Address - Country:US
Mailing Address - Phone:502-636-5492
Mailing Address - Fax:502-636-9210
Practice Address - Street 1:1504 S 7TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40208-1711
Practice Address - Country:US
Practice Address - Phone:502-636-5492
Practice Address - Fax:502-636-9210
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-19
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9263122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100238920Medicaid