Provider Demographics
NPI:1093902264
Name:MIDDLETON, CHARLES H (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:H
Last Name:MIDDLETON
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 1:4302 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-6988
Mailing Address - Country:US
Mailing Address - Phone:260-484-3136
Mailing Address - Fax:260-484-3137
Practice Address - Street 1:4302 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-6988
Practice Address - Country:US
Practice Address - Phone:260-484-3136
Practice Address - Fax:260-484-3137
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008119122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100079660AMedicaid
IN000055165OtherUNITED CONCORDIA