Provider Demographics
NPI:1649287038
Name:KING, CHARLES MARK (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MARK
Last Name:KING
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 1:6662 HIGHWAY 75
Mailing Address - Street 2:SUITE 114
Mailing Address - City:PINSON
Mailing Address - State:AL
Mailing Address - Zip Code:35126-3200
Mailing Address - Country:US
Mailing Address - Phone:205-681-5959
Mailing Address - Fax:205-681-5954
Practice Address - Street 1:6662 HIGHWAY 75
Practice Address - Street 2:SUITE 114
Practice Address - City:PINSON
Practice Address - State:AL
Practice Address - Zip Code:35126-3200
Practice Address - Country:US
Practice Address - Phone:205-681-5959
Practice Address - Fax:205-681-5954
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL36811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL01015OtherBLUECROSSBLUESHIELD