Provider Demographics
NPI:1245634682
Name:CHARLES DENTAL GROUP
Entity type:Organization
Organization Name:CHARLES DENTAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAIR
Authorized Official - Middle Name:VERNAL
Authorized Official - Last Name:MOSER
Authorized Official - Suffix:II
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-721-3368
Mailing Address - Street 1:12344 FAIR OAKS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-2546
Mailing Address - Country:US
Mailing Address - Phone:916-721-3367
Mailing Address - Fax:916-583-7445
Practice Address - Street 1:12344 FAIR OAKS BLVD STE A
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-2546
Practice Address - Country:US
Practice Address - Phone:916-721-3367
Practice Address - Fax:916-583-7445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40472122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty