MEDICARE: DR. CHARLES JASON PUTNAM 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	1223E0200X	Endodontics	4226	SC

General Provider Information

NPI Number	:	1538341888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES JASON PUTNAM DMD

Provider Business Mailing Address
First Line	:	25 CLARK SUMMIT DR
Second Line	:	SUITE 202 BOX 9
City	:	BLUFFTON
State	:	SC
Zip	:	29910-4205
Country	:	US
Telephone Number	:	843-837-8585
Fax Number	:	843-837-8587

Provider Business Practice Location Address
First Line	:	25 CLARK SUMMIT DR
Second Line	:	SUITE 202 BOX 9
City	:	BLUFFTON
State	:	SC
Zip	:	29910-4205
Country	:	US
Telephone Number	:	843-837-8585
Fax Number	:	843-837-8587

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

Provider Enumeration Date	:	11/28/2007
Last Update Date	:	11/28/2007

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