Provider Demographics
NPI:1477634434
Name:DECKER, CHARLES DWIGHT (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DWIGHT
Last Name:DECKER
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 1:36 PARK PLACE
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05345
Mailing Address - Country:US
Mailing Address - Phone:802-254-8322
Mailing Address - Fax:802-254-8322
Practice Address - Street 1:36 PARK PLACE
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05345
Practice Address - Country:US
Practice Address - Phone:802-254-8322
Practice Address - Fax:802-254-8322
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VTVT569122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH99001682Medicaid
VT0001830Medicaid