1144409921 NPI number — DR. CHARLES S. IRELAND III D.M.D

Table of content: DR. CHARLES S. IRELAND III D.M.D (NPI 1144409921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144409921 NPI number — DR. CHARLES S. IRELAND III D.M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IRELAND
Provider First Name:
CHARLES
Provider Middle Name:
S.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
D.M.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144409921
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2400 PERSHING AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSLYN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19001-1619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-706-0607
Provider Business Mailing Address Fax Number:
215-706-0260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 PERSHING AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSLYN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19001-1619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-706-0607
Provider Business Practice Location Address Fax Number:
215-706-0260
Provider Enumeration Date:
10/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DS025522-L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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