Provider Demographics
NPI:1972673598
Name:KOHOUT, CHARLES WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:KOHOUT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6636 MAIN ST
Mailing Address - Street 2:SUITE5
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5967
Mailing Address - Country:US
Mailing Address - Phone:716-633-4747
Mailing Address - Fax:716-633-0328
Practice Address - Street 1:6636 MAIN ST
Practice Address - Street 2:SUITE5
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5967
Practice Address - Country:US
Practice Address - Phone:716-633-4747
Practice Address - Fax:716-633-0328
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0349241223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01992378Medicaid