=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063430924
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES G. WOOD D.M.D.P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1213 BROAD AVE # STD-1
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39501-2475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-863-5171
-----------------------------------------------------
Fax | 228-863-5233
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1213 BROAD AVE # STD-1
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39501-2475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-863-5171
-----------------------------------------------------
Fax | 228-863-5233
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. CHARLES G WOOD
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 228-863-5171
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2041-83
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------