MEDICARE: DR. CHARLES ROBERT BROWN D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	5643	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5643	OTHER	FL	DENTAL LICENSE NUMBER

General Provider Information

NPI Number	:	1073613600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES ROBERT BROWN D.M.D.

Provider Business Mailing Address
First Line	:	6211 SANTA MONICA DR
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-5964
Country	:	US
Telephone Number	:	386-761-5546
Fax Number	:

Provider Business Practice Location Address
First Line	:	912 S RIDGEWOOD AVE
Second Line	:	SUITE B
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-5349
Country	:	US
Telephone Number	:	386-258-6132
Fax Number	:	386-239-0730

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2006
Last Update Date	:	07/09/2007

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