1679780902 NPI number — DR. CHARLES MICHAEL GILLIAM DDS

Table of content: DR. CHARLES MICHAEL GILLIAM DDS (NPI 1679780902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679780902 NPI number — DR. CHARLES MICHAEL GILLIAM DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILLIAM
Provider First Name:
CHARLES
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
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:
1679780902
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2700 NE 14TH STREET CSWY
Provider Second Line Business Mailing Address:
SUITE #105
Provider Business Mailing Address City Name:
POMPANO BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33062-3561
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-941-2412
Provider Business Mailing Address Fax Number:
954-784-7984

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 NE 14TH STREET CSWY
Provider Second Line Business Practice Location Address:
SUITE #105
Provider Business Practice Location Address City Name:
POMPANO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33062-3561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-941-2412
Provider Business Practice Location Address Fax Number:
954-784-7984
Provider Enumeration Date:
05/17/2007

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: 122300000X , with the licence number:  10912 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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