Provider Demographics
NPI:1720138852
Name:HANNA, CHARLES WALDEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WALDEN
Last Name:HANNA
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:PO BOX 2409
Mailing Address - Street 2:121 NORTH PINE STREET
Mailing Address - City:BATESBURG LEESVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29070-0409
Mailing Address - Country:US
Mailing Address - Phone:803-532-6146
Mailing Address - Fax:803-532-5807
Practice Address - Street 1:121 NORTH PINE STREET
Practice Address - Street 2:
Practice Address - City:BATESBURG LEESVILLE
Practice Address - State:SC
Practice Address - Zip Code:29006
Practice Address - Country:US
Practice Address - Phone:803-532-6146
Practice Address - Fax:803-532-5807
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1631122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ16313Medicaid