Provider Demographics
NPI:1366410839
Name:CONKLIN, CHARLES E JR (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
Last Name:CONKLIN
Suffix:JR
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 1:4569 KEAGY RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-7417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2017 JEFFERSON ST SW
Practice Address - Street 2:CARILION DENTAL CLINIC
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-2419
Practice Address - Country:US
Practice Address - Phone:540-981-7128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401-0049901223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7816146Medicaid
VA7805225Medicaid
T21659Medicare UPIN
VA7805225Medicaid