Provider Demographics
NPI:1972532398
Name:BROWN, CHARLES BERNARD (DDS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:BERNARD
Last Name:BROWN
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 1:58 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18407-2297
Mailing Address - Country:US
Mailing Address - Phone:570-282-4262
Mailing Address - Fax:
Practice Address - Street 1:58 8TH AVE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407-2297
Practice Address - Country:US
Practice Address - Phone:570-282-4262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS020132L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000508964Medicaid
PA013231Medicare ID - Type Unspecified
PA000508964Medicaid