Healthcare Provider Details

I. General information

NPI: 1497868632
Provider Name (Legal Business Name): CHARLES LEE MAHAFFEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 W BATTLEFIELD
SPRINGFIELD MO
65807
US

IV. Provider business mailing address

509 W BATTLEFIELD
SPRINGFIELD MO
65807
US

V. Phone/Fax

Practice location:
  • Phone: 417-887-3573
  • Fax: 417-887-3585
Mailing address:
  • Phone: 417-887-3573
  • Fax: 417-887-3585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number11799
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: