Provider Demographics
NPI:1023071149
Name:EBSWORTH, CHARLES FREDRICK (DDS)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:FREDRICK
Last Name:EBSWORTH
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 1:17191 BOTHELL WAY NE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155-5534
Mailing Address - Country:US
Mailing Address - Phone:206-362-0152
Mailing Address - Fax:206-365-3441
Practice Address - Street 1:17191 BOTHELL WAY NE
Practice Address - Street 2:SUITE 201
Practice Address - City:LAKE FOREST PARK
Practice Address - State:WA
Practice Address - Zip Code:98155-5534
Practice Address - Country:US
Practice Address - Phone:206-362-0152
Practice Address - Fax:206-365-3441
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA40731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice