Provider Demographics
NPI:1306854237
Name:MORITZ, CHARLES RANDALL (DDS PC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:RANDALL
Last Name:MORITZ
Suffix:
Gender:M
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 N OAK ST
Mailing Address - Street 2:SUITE C-1
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1744
Mailing Address - Country:US
Mailing Address - Phone:229-247-0200
Mailing Address - Fax:229-247-0200
Practice Address - Street 1:2704 N OAK ST
Practice Address - Street 2:SUITE C-1
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1744
Practice Address - Country:US
Practice Address - Phone:229-247-0200
Practice Address - Fax:229-247-0200
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0008063122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist