Provider Demographics
NPI:1760230858
Name:CHARLES ELIJAH DENTISTRY
Entity type:Organization
Organization Name:CHARLES ELIJAH DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIJAH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:334-678-1727
Mailing Address - Street 1:318 HEALTHWEST DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-1907
Mailing Address - Country:US
Mailing Address - Phone:334-678-1727
Mailing Address - Fax:334-678-1521
Practice Address - Street 1:318 HEALTHWEST DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-1907
Practice Address - Country:US
Practice Address - Phone:334-678-1727
Practice Address - Fax:334-678-1521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental