Healthcare Provider Details

I. General information

NPI: 1649621400
Provider Name (Legal Business Name): DR. CHARLES WALTER WOODRUFF II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 06/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JOINT BASE LEWIS-MCCORD DENTAC DENTAL CLINIC 3
JBLM WA
98327
US

IV. Provider business mailing address

2220 WESTRIDGE AVE W D101
TACOMA WA
98466-1841
US

V. Phone/Fax

Practice location:
  • Phone: 253-966-7855
  • Fax:
Mailing address:
  • Phone: 602-820-9502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60599190
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: