Provider Demographics
NPI:1912903196
Name:WALSTON, CHARLOTTE ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLOTTE
Middle Name:ANN
Last Name:WALSTON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5443 EVERHART RD
Mailing Address - Street 2:STE B
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-4888
Mailing Address - Country:US
Mailing Address - Phone:361-854-1234
Mailing Address - Fax:361-854-1292
Practice Address - Street 1:5443 EVERHART RD
Practice Address - Street 2:STE B
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4888
Practice Address - Country:US
Practice Address - Phone:361-854-1234
Practice Address - Fax:361-854-1292
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX148301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice