MEDICARE: CHARLES A. POBLENZ DMD

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	1223G0001X	General Practice Dentistry	DN 21362	FL

General Provider Information

NPI Number	:	1134501141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES A. POBLENZ DMD

Provider Business Mailing Address
First Line	:	3647 HENDRICKS AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-5360
Country	:	US
Telephone Number	:	904-396-4091
Fax Number	:	904-396-9091

Provider Business Practice Location Address
First Line	:	3647 HENDRICKS AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-5360
Country	:	US
Telephone Number	:	904-396-4091
Fax Number	:	904-396-9091

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

Provider Enumeration Date	:	06/25/2015
Last Update Date	:	07/17/2020

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