Provider Demographics
NPI:1669514097
Name:HAJINIAN, CHARLES ALLEN (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALLEN
Last Name:HAJINIAN
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 1:663 GARRISON CT
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-2021
Mailing Address - Country:US
Mailing Address - Phone:262-646-5808
Mailing Address - Fax:
Practice Address - Street 1:10425 W NORTH AVE STE 302
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-2416
Practice Address - Country:US
Practice Address - Phone:414-259-9400
Practice Address - Fax:414-259-9446
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33388100Medicaid
WI38383600Medicaid