Provider Demographics
NPI:1295804037
Name:KING, CHARLES CLINTON SR (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:CLINTON
Last Name:KING
Suffix:SR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:605 HONEYSUCKLE DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31705-9177
Mailing Address - Country:US
Mailing Address - Phone:229-435-7732
Mailing Address - Fax:229-439-0533
Practice Address - Street 1:915 W HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-2735
Practice Address - Country:US
Practice Address - Phone:229-435-0677
Practice Address - Fax:229-439-0533
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0096431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000247288-AMedicaid