Provider Demographics
NPI:1801911029
Name:LAURENCE, CHARLES J (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:LAURENCE
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 1:1704 HUNGERS PARISH CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-7013
Mailing Address - Country:US
Mailing Address - Phone:757-460-4435
Mailing Address - Fax:
Practice Address - Street 1:NAVAL MEDICAL CENTER PORTSMOUTH
Practice Address - Street 2:620 JOHN PAUL JONES CIR.
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708
Practice Address - Country:US
Practice Address - Phone:757-953-8637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010064011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
794586OtherTRICARE
179332OtherANTHEM