MEDICARE: CHARLES P. COLUMPAR, JR., DMD, INC.

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	122300000X	Dentist	1600	RI
2	122300000X	Dentist	1518	RI

General Provider Information

NPI Number	:	1124278247
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLES P. COLUMPAR, JR., DMD, INC.

Provider Business Mailing Address
First Line	:	477 E MAIN RD
Second Line	:
City	:	MIDDLETOWN
State	:	RI
Zip	:	02842-5202
Country	:	US
Telephone Number	:	401-846-6265
Fax Number	:	401-846-1648

Provider Business Practice Location Address
First Line	:	477 E MAIN RD
Second Line	:
City	:	MIDDLETOWN
State	:	RI
Zip	:	02842-5202
Country	:	US
Telephone Number	:	401-846-6265
Fax Number	:	401-846-1648

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. WAYNE ANTHONY LABORE
Credential	:	DDS
Telephone Number	:	401-846-6265

Provider Enumeration Date	:	09/25/2008
Last Update Date	:	09/25/2008

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