Provider Demographics
NPI:1033608807
Name:CHARLY, DOREEN MARIO
Entity type:Individual
Prefix:MISS
First Name:DOREEN
Middle Name:MARIO
Last Name:CHARLY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 BRISTOL CT
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07035-1743
Mailing Address - Country:US
Mailing Address - Phone:832-350-2063
Mailing Address - Fax:
Practice Address - Street 1:475 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305
Practice Address - Country:US
Practice Address - Phone:718-226-8855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI027412001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice