Provider Demographics
NPI:1063584399
Name:LANDIS, CHARLES RANDOLPH (DDS, OMS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RANDOLPH
Last Name:LANDIS
Suffix:
Gender:M
Credentials:DDS, OMS
Other - Prefix:DR
Other - First Name:C.
Other - Middle Name:RANDY
Other - Last Name:LANDIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS, OMS
Mailing Address - Street 1:2619 FOREST AVE
Mailing Address - Street 2:STE 120
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-4390
Mailing Address - Country:US
Mailing Address - Phone:530-893-3912
Mailing Address - Fax:530-893-2451
Practice Address - Street 1:2990 ORO DAM BLVD E
Practice Address - Street 2:STE C
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966-5190
Practice Address - Country:US
Practice Address - Phone:530-533-7900
Practice Address - Fax:530-533-3457
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA319401223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB31940Medicaid
U34606Medicare UPIN
U34606Medicare UPIN