Provider Demographics
NPI:1043041403
Name:IDLETT, CHARMAINE (RDH)
Entity type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:
Last Name:IDLETT
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 N. WESTOVER BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707
Mailing Address - Country:US
Mailing Address - Phone:229-405-6249
Mailing Address - Fax:229-329-4373
Practice Address - Street 1:GLOVER DENTAL CENTER
Practice Address - Street 2:2607 GILLIONVILLE RD
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707
Practice Address - Country:US
Practice Address - Phone:229-883-9001
Practice Address - Fax:229-888-3342
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADH012822124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist