Provider Demographics
NPI:1447441761
Name:SAMMONS, CHARLES EDWARD (DDS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWARD
Last Name:SAMMONS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 MINGO AVE
Mailing Address - Street 2:
Mailing Address - City:KERMIT
Mailing Address - State:WV
Mailing Address - Zip Code:25674
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:180 MINGO AVE
Practice Address - Street 2:
Practice Address - City:KERMIT
Practice Address - State:WV
Practice Address - Zip Code:25674
Practice Address - Country:US
Practice Address - Phone:304-393-1030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2668122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0136867000Medicaid