Provider Demographics
NPI:1184723801
Name:SU, CHARLES (DDS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:SU
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 1:7275 E SOUTHGATE DR
Mailing Address - Street 2:205
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2628
Mailing Address - Country:US
Mailing Address - Phone:916-399-1318
Mailing Address - Fax:
Practice Address - Street 1:7275 E SOUTHGATE DR
Practice Address - Street 2:205
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2628
Practice Address - Country:US
Practice Address - Phone:916-399-1318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA420961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB42096Medicaid