Provider Demographics
NPI:1992208946
Name:MAIZARES, CHARLIE BRIAN
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:BRIAN
Last Name:MAIZARES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 OVERLEAF WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92582-3788
Mailing Address - Country:US
Mailing Address - Phone:951-350-3459
Mailing Address - Fax:
Practice Address - Street 1:3027 W FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-3617
Practice Address - Country:US
Practice Address - Phone:951-330-4618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72458126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA72458Medicaid