Provider Demographics
NPI:1215316765
Name:CHARGING, MALLORY (DDS)
Entity type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:
Last Name:CHARGING
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WITTENBERG
Mailing Address - State:WI
Mailing Address - Zip Code:54499-7600
Mailing Address - Country:US
Mailing Address - Phone:715-253-3200
Mailing Address - Fax:
Practice Address - Street 1:202 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:WITTENBERG
Practice Address - State:WI
Practice Address - Zip Code:54499-7600
Practice Address - Country:US
Practice Address - Phone:715-253-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10011021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice