Provider Demographics
NPI:1699884478
Name:SAMPOGNARO, CHARLES M (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:SAMPOGNARO
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 1:1219 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5435
Mailing Address - Country:US
Mailing Address - Phone:318-387-2145
Mailing Address - Fax:318-323-7739
Practice Address - Street 1:1219 N 19TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5435
Practice Address - Country:US
Practice Address - Phone:318-387-2145
Practice Address - Fax:318-323-7739
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA38831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice