MEDICARE: DR. THOMAS D CHARBENEAU DDS, MSD, PA

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	1223P0300X	Periodontics	11554	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1568474989	OTHER	TX	CORPORATION

General Provider Information

NPI Number	:	1588855456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS D CHARBENEAU DDS, MSD, PA

Provider Business Mailing Address
First Line	:	3420 CLARKSVILLE ST
Second Line	:	P.O. BOX 6578
City	:	PARIS
State	:	TX
Zip	:	75460-8014
Country	:	US
Telephone Number	:	903-785-4832
Fax Number	:	903-785-3807

Provider Business Practice Location Address
First Line	:	3420 CLARKSVILLE ST
Second Line	:
City	:	PARIS
State	:	TX
Zip	:	75460-8014
Country	:	US
Telephone Number	:	903-785-4832
Fax Number	:	903-785-3807

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

Provider Enumeration Date	:	08/06/2007
Last Update Date	:	08/06/2007

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