MEDICARE: CHARLES WILLIAM DORMAN JR. DDS MS

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	1223P0700X	Prosthodontics	22339	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	22339	OTHER	CA	CA. DENTAL LICENSE NUMBER

General Provider Information

NPI Number	:	1922173632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES WILLIAM DORMAN JR. DDS MS

Provider Business Mailing Address
First Line	:	4637 QUAIL LAKES DR
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-5258
Country	:	US
Telephone Number	:	209-235-7207
Fax Number	:	209-235-7210

Provider Business Practice Location Address
First Line	:	4637 QUAIL LAKES DR
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-5258
Country	:	US
Telephone Number	:	209-235-7207
Fax Number	:	209-235-7210

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

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	07/08/2007

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