Provider Demographics
NPI:1255629390
Name:CHARLIE BULLER III DDS
Entity type:Organization
Organization Name:CHARLIE BULLER III DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLER
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:337-582-7225
Mailing Address - Street 1:PO BOX 1179
Mailing Address - Street 2:
Mailing Address - City:IOWA
Mailing Address - State:LA
Mailing Address - Zip Code:70647-1179
Mailing Address - Country:US
Mailing Address - Phone:337-582-7225
Mailing Address - Fax:337-582-4867
Practice Address - Street 1:206 THOMSON AVE.
Practice Address - Street 2:
Practice Address - City:IOWA
Practice Address - State:LA
Practice Address - Zip Code:70647-1179
Practice Address - Country:US
Practice Address - Phone:337-582-7225
Practice Address - Fax:337-582-4867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6173122300000X
LA4022122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1840220Medicaid