Healthcare Provider Details

I. General information

NPI: 1851462980
Provider Name (Legal Business Name): CHARLES WILLIAM BARTHOLOMEW JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2006
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 S LAFOUNTAIN ST SUITE C
KOKOMO IN
46902-3802
US

IV. Provider business mailing address

3415 S LAFOUNTAIN ST SUITE C
KOKOMO IN
46902-3802
US

V. Phone/Fax

Practice location:
  • Phone: 765-453-0291
  • Fax:
Mailing address:
  • Phone: 765-453-0291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12009183
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: