Provider Demographics
NPI:1962544197
Name:CHARLES R DISDIER DDS PA
Entity type:Organization
Organization Name:CHARLES R DISDIER DDS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:DISDIER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:252-243-8448
Mailing Address - Street 1:1468 TARBORO ST W
Mailing Address - Street 2:SUITE F
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-1509
Mailing Address - Country:US
Mailing Address - Phone:252-243-8448
Mailing Address - Fax:252-243-9503
Practice Address - Street 1:1468 TARBORO ST W
Practice Address - Street 2:SUITE F
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-1509
Practice Address - Country:US
Practice Address - Phone:252-243-8448
Practice Address - Fax:252-243-9503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC69751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901593Medicaid