Provider Demographics
NPI:1306936547
Name:WRIGHT, CHARLES RUSSELL (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RUSSELL
Last Name:WRIGHT
Suffix:
Gender:M
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:PO BOX 484
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-0484
Mailing Address - Country:US
Mailing Address - Phone:678-925-1077
Mailing Address - Fax:
Practice Address - Street 1:2129 GRANDVIEW RD
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-3313
Practice Address - Country:US
Practice Address - Phone:678-925-1077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA81051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice