Provider Demographics
NPI:1992097752
Name:SHORT, CHARLES ARTHUR (DDS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ARTHUR
Last Name:SHORT
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 1:5406 39TH ST
Mailing Address - Street 2:
Mailing Address - City:GROVES
Mailing Address - State:TX
Mailing Address - Zip Code:77619-2914
Mailing Address - Country:US
Mailing Address - Phone:409-962-3733
Mailing Address - Fax:409-962-5757
Practice Address - Street 1:5406 39TH ST
Practice Address - Street 2:
Practice Address - City:GROVES
Practice Address - State:TX
Practice Address - Zip Code:77619-2914
Practice Address - Country:US
Practice Address - Phone:409-962-3733
Practice Address - Fax:409-962-5757
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX127611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice