Provider Demographics
NPI:1861593410
Name:WOODYARD, CHARLES J (DDS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:WOODYARD
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 1:407 S GOULD AVE
Mailing Address - Street 2:
Mailing Address - City:GOULD
Mailing Address - State:AR
Mailing Address - Zip Code:71643-5041
Mailing Address - Country:US
Mailing Address - Phone:870-263-4317
Mailing Address - Fax:870-263-4782
Practice Address - Street 1:407 S GOULD AVE
Practice Address - Street 2:
Practice Address - City:GOULD
Practice Address - State:AR
Practice Address - Zip Code:71643-5041
Practice Address - Country:US
Practice Address - Phone:870-263-4317
Practice Address - Fax:870-263-4782
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1969122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK149324631Medicaid
AK149324631Medicaid