Provider Demographics
NPI:1023324621
Name:BRIAN W CHARLES DMD
Entity type:Organization
Organization Name:BRIAN W CHARLES DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-634-7653
Mailing Address - Street 1:509 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-5017
Mailing Address - Country:US
Mailing Address - Phone:208-634-7653
Mailing Address - Fax:208-634-4568
Practice Address - Street 1:509 PINE ST
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-5017
Practice Address - Country:US
Practice Address - Phone:208-634-7653
Practice Address - Fax:208-634-4568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-08582261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002547300Medicaid