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General NPI Number Information
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NPI Number | 1538219803
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Entity Type | Individual
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Provider Name | CHARLES DUDLEY PARKS D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 01/11/2007
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Last Update Date | 05/21/2020
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Provider Practice Location Address
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Address Line | 5004 BRAMBLETON AVE
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City | ROANOKE
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State | VA
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Zip | 24018-4642
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Country | US
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Telephone | 540-774-1019
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Fax |
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Provider Business Mailing Address
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Address Line | 6635 MOUNT CHESTNUT RD
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City | ROANOKE
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State | VA
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Zip | 24018-8111
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Country | US
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Telephone | 540-989-9305
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 0401008066
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License Number State | VA
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