Provider Demographics
NPI:1770563736
Name:HADDAD, CHARLES J JR (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:HADDAD
Suffix:JR
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 1:510 SUPERIOR AVE E
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114
Mailing Address - Country:US
Mailing Address - Phone:216-621-3675
Mailing Address - Fax:216-621-9790
Practice Address - Street 1:510 SUPERIOR AVE E
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114
Practice Address - Country:US
Practice Address - Phone:216-621-3675
Practice Address - Fax:216-621-9790
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30017739122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0560254Medicaid