Healthcare Provider Details

I. General information

NPI: 1376590133
Provider Name (Legal Business Name): CHARLES ANTHONY LOSCHIAVO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2370 N WYATT DR
TUCSON AZ
85712-2119
US

IV. Provider business mailing address

2370 N WYATT DR
TUCSON AZ
85712-2119
US

V. Phone/Fax

Practice location:
  • Phone: 520-322-0661
  • Fax: 520-322-0411
Mailing address:
  • Phone: 520-322-0661
  • Fax: 520-322-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD3641
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: