Basic Information
| Provider Information | |||||||||
| NPI: | 1003014093 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DRURY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | LEO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5256 S MISSON RD | ||||||||
| Address2: | SUITE 1101 | ||||||||
| City: | BONSALL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920033624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606305500 | ||||||||
| FaxNumber: | 7606305831 | ||||||||
| Practice Location | |||||||||
| Address1: | 5256 S MISSON RD | ||||||||
| Address2: | SUITE 1101 | ||||||||
| City: | BONSALL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920033624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606305500 | ||||||||
| FaxNumber: | 7606305831 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2007 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 48905 | CA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 1753898 | 01 | UNITED CONCORDIA | OTHER | 48905 | 01 | DELTA | OTHER |