Provider Demographics
NPI:1265601512
Name:CHARLES G ST JOHN DMD PC
Entity type:Organization
Organization Name:CHARLES G ST JOHN DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:GUERIN
Authorized Official - Last Name:ST JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:413-684-1240
Mailing Address - Street 1:251 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:MA
Mailing Address - Zip Code:01226-1642
Mailing Address - Country:US
Mailing Address - Phone:413-684-1240
Mailing Address - Fax:413-684-8925
Practice Address - Street 1:251 MAIN ST
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:MA
Practice Address - Zip Code:01226-1642
Practice Address - Country:US
Practice Address - Phone:413-684-1240
Practice Address - Fax:413-684-8925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13458122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX10161OtherBC/BS