Provider Demographics
NPI:1831353747
Name:LATHAM, CHRISTOPHER WRIGHT (DMD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:WRIGHT
Last Name:LATHAM
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 1:2047 PARK ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-3809
Mailing Address - Country:US
Mailing Address - Phone:904-388-7665
Mailing Address - Fax:
Practice Address - Street 1:2047 PARK ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3809
Practice Address - Country:US
Practice Address - Phone:904-388-7665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12636204E00000X
MN56616204E00000X
FL18401204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNENROLLEDMedicaid