Healthcare Provider Details

I. General information

NPI: 1326163809
Provider Name (Legal Business Name): CHARLES RANDLE DILLARD JR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4330 HIGHWAY 78 E SUITE 200
JASPER AL
35501-8905
US

IV. Provider business mailing address

4330 HIGHWAY 78 E SUITE 200
JASPER AL
35501-8905
US

V. Phone/Fax

Practice location:
  • Phone: 202-295-2992
  • Fax: 205-384-1291
Mailing address:
  • Phone: 202-295-2992
  • Fax: 205-384-1291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number4917
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: