MEDICARE: THOMAS D. CHARBENEAU, DDS, MSD, PA

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	1223P0300X	Periodontics	11554	TX

General Provider Information

NPI Number	:	1568474989
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THOMAS D. CHARBENEAU, DDS, MSD, PA

Provider Business Mailing Address
First Line	:	3420 CLARKSVILLE ST
Second Line	:
City	:	PARIS
State	:	TX
Zip	:	75460-8014
Country	:	US
Telephone Number	:	903-785-4832
Fax Number	:	903-785-3807

Provider Business Practice Location Address
First Line	:	3420 CLARKSVILLE ST
Second Line	:
City	:	PARIS
State	:	TX
Zip	:	75460-8014
Country	:	US
Telephone Number	:	903-785-4832
Fax Number	:	903-785-3807

Authorized Official
Title or Position	:	OWNER
Name	:	DR. THOMAS D. CHARBENEAU
Credential	:	D.D.S.
Telephone Number	:	903-785-4832

Provider Enumeration Date	:	08/13/2006
Last Update Date	:	08/22/2020

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