Provider Demographics
NPI:1811158876
Name:VANDERPOOL, CHARLES H (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:H
Last Name:VANDERPOOL
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 457
Mailing Address - Street 2:
Mailing Address - City:GANADO
Mailing Address - State:AZ
Mailing Address - Zip Code:86505-0457
Mailing Address - Country:US
Mailing Address - Phone:928-755-4500
Mailing Address - Fax:928-755-4815
Practice Address - Street 1:HWY 264 AND JUNCTION 191 S
Practice Address - Street 2:
Practice Address - City:GANADO
Practice Address - State:AZ
Practice Address - Zip Code:86505
Practice Address - Country:US
Practice Address - Phone:928-755-4500
Practice Address - Fax:928-755-4815
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD2521122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist