MEDICARE: DR. CHARLESPAUL T ANONUEVO DDS

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	019027110	IL
2	122300000X	Dentist	8858	NC

General Provider Information

NPI Number	:	1558379347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLESPAUL T ANONUEVO DDS

Provider Business Mailing Address
First Line	:	8810 BLAKENEY PROFESSIONAL DR STE 120
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-6654
Country	:	US
Telephone Number	:	704-540-1900
Fax Number	:	844-891-7162

Provider Business Practice Location Address
First Line	:	8810 BLAKENEY PROFESSIONAL DR STE 120
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-6654
Country	:	US
Telephone Number	:	704-540-1900
Fax Number	:	844-891-7162

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

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	07/21/2022

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