Provider Demographics
NPI:1083727291
Name:CHARLES R. HUTTON D.D.S.,PC
Entity Type:Organization
Organization Name:CHARLES R. HUTTON D.D.S.,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:HUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-946-6820
Mailing Address - Street 1:201 E ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:WINAMAC
Mailing Address - State:IN
Mailing Address - Zip Code:46996-1567
Mailing Address - Country:US
Mailing Address - Phone:574-946-6820
Mailing Address - Fax:574-946-4323
Practice Address - Street 1:201 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:WINAMAC
Practice Address - State:IN
Practice Address - Zip Code:46996-1567
Practice Address - Country:US
Practice Address - Phone:574-946-6820
Practice Address - Fax:574-946-4323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN54000691A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100210570AMedicaid