Provider Demographics
NPI:1104133966
Name:MOOREHEAD, CHARLES DOUGLAS (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DOUGLAS
Last Name:MOOREHEAD
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 1:10427 KENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-3823
Mailing Address - Country:US
Mailing Address - Phone:513-984-3817
Mailing Address - Fax:513-984-3818
Practice Address - Street 1:10427 KENWOOD RD
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-3823
Practice Address - Country:US
Practice Address - Phone:513-984-3817
Practice Address - Fax:513-984-3818
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-023252122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist