Provider Demographics
NPI:1336272335
Name:CHARBONNEAU, EDWARD LEE (DDS)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:LEE
Last Name:CHARBONNEAU
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 1:1520 W GARLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205
Mailing Address - Country:US
Mailing Address - Phone:509-328-9787
Mailing Address - Fax:509-326-8095
Practice Address - Street 1:1520 W GARLAND AVENUE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205
Practice Address - Country:US
Practice Address - Phone:509-328-9787
Practice Address - Fax:509-326-8095
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA4478122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist