Provider Demographics
NPI:1649357450
Name:HIERONIMUS, CHARLES KEITH (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:KEITH
Last Name:HIERONIMUS
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:RD #3 BOX 501
Mailing Address - Street 2:SHERRAND
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003
Mailing Address - Country:US
Mailing Address - Phone:304-232-5101
Mailing Address - Fax:304-232-1252
Practice Address - Street 1:RD #3 BOX 501
Practice Address - Street 2:SHERRAND
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003
Practice Address - Country:US
Practice Address - Phone:304-232-5101
Practice Address - Fax:304-232-1252
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV2417122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist