Healthcare Provider Details

I. General information

NPI: 1821119918
Provider Name (Legal Business Name): CHARLES CALDWELL DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3875 BURTON ST SE
GRAND RAPIDS MI
49546-5816
US

IV. Provider business mailing address

3875 BURTON ST SE
GRAND RAPIDS MI
49546-5816
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-7510
  • Fax: 616-949-6051
Mailing address:
  • Phone: 616-949-7510
  • Fax: 616-949-6051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901011536
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: