Provider Demographics
NPI:1962500868
Name:BRUNSON, CHARLES W (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:BRUNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 MATTOX CREEK DR
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-7634
Mailing Address - Country:US
Mailing Address - Phone:706-595-7264
Mailing Address - Fax:
Practice Address - Street 1:115 GORDON ST
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-1537
Practice Address - Country:US
Practice Address - Phone:706-595-3462
Practice Address - Fax:706-595-3616
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice