Provider Demographics
NPI:1528161791
Name:TZAGOURNIS, CHARLES (DDS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:TZAGOURNIS
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 1:393 E TOWN ST
Mailing Address - Street 2:SUITE 117
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-4741
Mailing Address - Country:US
Mailing Address - Phone:614-224-4039
Mailing Address - Fax:614-224-4039
Practice Address - Street 1:393 E TOWN ST
Practice Address - Street 2:SUITE 117
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4741
Practice Address - Country:US
Practice Address - Phone:614-224-4039
Practice Address - Fax:614-224-4039
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH129951223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH310791883026OtherCARESOURCE
OH605886OtherCOMPDENT
OH0133215Medicaid
OH0133215Medicaid
OHT46742Medicare UPIN