Provider Demographics
NPI:1962686071
Name:BRANDENBURG, CHARLES L III (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:BRANDENBURG
Suffix:III
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 1:5011D MACKAY RD
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27282
Mailing Address - Country:US
Mailing Address - Phone:336-852-8383
Mailing Address - Fax:336-856-1318
Practice Address - Street 1:5011D MACKAY RD
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NC
Practice Address - Zip Code:27282
Practice Address - Country:US
Practice Address - Phone:336-852-8383
Practice Address - Fax:336-856-1318
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6010122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist