Provider Demographics
NPI:1679780902
Name:GILLIAM, CHARLES MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MICHAEL
Last Name:GILLIAM
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 1:2700 NE 14TH STREET CSWY
Mailing Address - Street 2:SUITE #105
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-3561
Mailing Address - Country:US
Mailing Address - Phone:954-941-2412
Mailing Address - Fax:954-784-7984
Practice Address - Street 1:2700 NE 14TH STREET CSWY
Practice Address - Street 2:SUITE #105
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-3561
Practice Address - Country:US
Practice Address - Phone:954-941-2412
Practice Address - Fax:954-784-7984
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10912122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist