Provider Demographics
NPI:1972642023
Name:SPATZ, CHARLES MELVYN (DMD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MELVYN
Last Name:SPATZ
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 1:1574 CHAPEL STREET
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-4205
Mailing Address - Country:US
Mailing Address - Phone:203-865-1480
Mailing Address - Fax:203-865-0290
Practice Address - Street 1:1574 CHAPEL STREET
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4205
Practice Address - Country:US
Practice Address - Phone:203-865-1480
Practice Address - Fax:203-865-0290
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4296122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT8034743Medicaid
CT2042968Medicaid