Provider Demographics
NPI:1336203827
Name:DERMODY, CHARLES PAUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PAUL
Last Name:DERMODY
Suffix:
Gender:M
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:PO BOX 7309
Mailing Address - Street 2:
Mailing Address - City:SIASCONSET
Mailing Address - State:MA
Mailing Address - Zip Code:02564-7309
Mailing Address - Country:US
Mailing Address - Phone:845-264-1361
Mailing Address - Fax:
Practice Address - Street 1:274 BARNSTABLE RD
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-2919
Practice Address - Country:US
Practice Address - Phone:508-771-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033152-1122300000X
MADN18564411223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist