MEDICARE: DR. CHARLES EDWARD MIDDLETON III DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	17155	TX

General Provider Information

NPI Number	:	1326047861
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES EDWARD MIDDLETON III DDS

Provider Business Mailing Address
First Line	:	4869 SPRING RIDGE DR
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31909-2049
Country	:	US
Telephone Number	:	706-575-5671
Fax Number	:

Provider Business Practice Location Address
First Line	:	1061 HARMON AVE
Second Line	:	DEPARTMENT ORAL AND MAXILLOFACIAL SURGERY
City	:	FT STEWART
State	:	GA
Zip	:	31314-5604
Country	:	US
Telephone Number	:	912-435-6248
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	07/08/2007

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