Provider Demographics
NPI:1437168028
Name:MEDEARIS, CHARLES R (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:MEDEARIS
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 1:1902 COUNTRY CLUB DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-5811
Mailing Address - Country:US
Mailing Address - Phone:972-416-4272
Mailing Address - Fax:972-418-9103
Practice Address - Street 1:1902 COUNTRY CLUB DR
Practice Address - Street 2:SUITE 150
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-5811
Practice Address - Country:US
Practice Address - Phone:972-416-4272
Practice Address - Fax:972-418-9103
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15352TX1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice