MEDICARE: DR. CHARLES MICHAEL GILLIAM 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	122300000X	Dentist	10912	FL

General Provider Information

NPI Number	:	1679780902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES MICHAEL GILLIAM DDS

Provider Business Mailing Address
First Line	:	2700 NE 14TH STREET CSWY
Second Line	:	SUITE #105
City	:	POMPANO BEACH
State	:	FL
Zip	:	33062-3561
Country	:	US
Telephone Number	:	954-941-2412
Fax Number	:	954-784-7984

Provider Business Practice Location Address
First Line	:	2700 NE 14TH STREET CSWY
Second Line	:	SUITE #105
City	:	POMPANO BEACH
State	:	FL
Zip	:	33062-3561
Country	:	US
Telephone Number	:	954-941-2412
Fax Number	:	954-784-7984

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

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	07/08/2007

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