Healthcare Provider Details

I. General information

NPI: 1871607879
Provider Name (Legal Business Name): CHARLES L.. CHAMBERS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 S ELLIOTT AVE STE A
AURORA MO
65605-2154
US

IV. Provider business mailing address

1402 S ELLIOTT AVE STE A
AURORA MO
65605-2154
US

V. Phone/Fax

Practice location:
  • Phone: 417-678-5958
  • Fax: 417-678-1519
Mailing address:
  • Phone: 417-678-5958
  • Fax: 417-678-1519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12124
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5135
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: