Provider Demographics
NPI:1396911681
Name:COLEMAN, CHARLES (DMD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4223 S DERBIGNY ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70125-5107
Mailing Address - Country:US
Mailing Address - Phone:504-342-4733
Mailing Address - Fax:
Practice Address - Street 1:3712 MACARTHUR BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70114-6802
Practice Address - Country:US
Practice Address - Phone:504-361-3277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5013122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1850136Medicaid
LA4B403F300Medicare PIN
LAU79697Medicare UPIN