Healthcare Provider Details

I. General information

NPI: 1215094230
Provider Name (Legal Business Name): CHARLES EUGENE WILLARD DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 E MAIN ST
WARE SHOALS SC
29692-1338
US

IV. Provider business mailing address

27 E MAIN ST
WARE SHOALS SC
29692-1338
US

V. Phone/Fax

Practice location:
  • Phone: 864-456-2521
  • Fax:
Mailing address:
  • Phone: 864-456-2521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2843
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: