Provider Demographics
NPI:1801170923
Name:CHARLES M SPATZ
Entity type:Organization
Organization Name:CHARLES M SPATZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:M
Authorized Official - Last Name:SPATZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-865-1480
Mailing Address - Street 1:1574 CHAPEL ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-4205
Mailing Address - Country:US
Mailing Address - Phone:203-865-1480
Mailing Address - Fax:203-865-0290
Practice Address - Street 1:1574 CHAPEL ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4205
Practice Address - Country:US
Practice Address - Phone:203-865-1480
Practice Address - Fax:203-865-0290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-07
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4296122300000X, 1223G0001X
CT8938122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty