Provider Demographics
NPI:1649292939
Name:BROWN, CHARLES IVAN JR (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:IVAN
Last Name:BROWN
Suffix:JR
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 1:5921 NE 199TH ST
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-3107
Mailing Address - Country:US
Mailing Address - Phone:843-224-2714
Mailing Address - Fax:
Practice Address - Street 1:16550 177TH AVENUE SE
Practice Address - Street 2:TWIN RIVERS UNIT
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272
Practice Address - Country:US
Practice Address - Phone:360-794-2451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4215122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist