Provider Demographics
NPI:1912980244
Name:GUEVARA, CHARLES EDWARD (BA DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWARD
Last Name:GUEVARA
Suffix:
Gender:M
Credentials:BA DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 STEILEN AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-2800
Mailing Address - Country:US
Mailing Address - Phone:201-321-2516
Mailing Address - Fax:201-670-6371
Practice Address - Street 1:175 ROUTE 59
Practice Address - Street 2:BEN GILMAN SPRING VALLEY MEDICAL & DENTAL CLINIC
Practice Address - City:SPRING VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10977-5231
Practice Address - Country:US
Practice Address - Phone:845-426-5800
Practice Address - Fax:845-356-4467
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035435122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00826673Medicaid