Provider Demographics
NPI:1124152517
Name:OATES, CHARLES BONNER (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BONNER
Last Name:OATES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:C
Other - Middle Name:BONNER
Other - Last Name:OATES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:210 NEEL AVE
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-4649
Mailing Address - Country:US
Mailing Address - Phone:505-835-1623
Mailing Address - Fax:505-835-3033
Practice Address - Street 1:210 NEEL AVE
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-4649
Practice Address - Country:US
Practice Address - Phone:505-835-1623
Practice Address - Fax:505-835-3033
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD13851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM6465Medicaid
NM00084517Medicaid