Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 8119 | TN |
NPI | 1437238052 |
---|---|
Provider Name | Dr. Tracey Roseann Charles |
First Address | Bemidji, MN 56601 |
Second Address | Bemidji, MN 56601 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/11/2006 |
Last Update Date | 08/07/2007 |