Provider Demographics
NPI:1700995727
Name:MARVIN, CHARLES M (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:MARVIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:978 ROUTE 45
Mailing Address - Street 2:NORTHSIDE PLAZA, SUITE 207
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-3521
Mailing Address - Country:US
Mailing Address - Phone:845-354-4600
Mailing Address - Fax:845-354-4653
Practice Address - Street 1:978 ROUTE 45
Practice Address - Street 2:NORTHSIDE PLAZA, SUITE 207
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-3521
Practice Address - Country:US
Practice Address - Phone:845-354-4600
Practice Address - Fax:845-354-4653
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048411-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02042 244Medicaid