Provider Demographics
NPI:1962857698
Name:MACK, CHARLES RUSSELL (DDS)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:RUSSELL
Last Name:MACK
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 1:1113 LAKEVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067
Mailing Address - Country:US
Mailing Address - Phone:615-790-6213
Mailing Address - Fax:615-790-8440
Practice Address - Street 1:1113 LAKEVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067
Practice Address - Country:US
Practice Address - Phone:615-790-6213
Practice Address - Fax:615-790-8440
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-02
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN105361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice