Provider Demographics
NPI:1881965564
Name:STEWART, CHARLES LEO (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LEO
Last Name:STEWART
Suffix:
Gender:M
Credentials:DMD
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Mailing Address - Street 1:4089 VAL TECH RD
Mailing Address - Street 2:WIREGRASS GEORGIA TECHNICAL COLLEGE, BERRIEN HALL
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-0929
Mailing Address - Country:US
Mailing Address - Phone:229-245-3716
Mailing Address - Fax:229-245-6513
Practice Address - Street 1:4089 VAL TECH RD
Practice Address - Street 2:WIREGRASS GEORGIA TECHNICAL COLLEGE, BERRIEN HALL
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-0929
Practice Address - Country:US
Practice Address - Phone:229-245-3716
Practice Address - Fax:229-245-6513
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GADN0097831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice