Provider Demographics
NPI:1205907797
Name:HOSTNIK, CHARLES TRAVIS (DMD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:TRAVIS
Last Name:HOSTNIK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:764 PALMER AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748
Mailing Address - Country:US
Mailing Address - Phone:732-495-8100
Mailing Address - Fax:732-495-0203
Practice Address - Street 1:764 PALMER AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748
Practice Address - Country:US
Practice Address - Phone:732-495-8100
Practice Address - Fax:732-495-0203
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01274200122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist