Provider Demographics
NPI:1104020015
Name:ANDERSON, CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:ANDERSON
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 1:4217 W TUMBLE CREEK CT
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-9499
Mailing Address - Country:US
Mailing Address - Phone:414-858-9935
Mailing Address - Fax:
Practice Address - Street 1:7218 S 76TH ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-9041
Practice Address - Country:US
Practice Address - Phone:414-425-2900
Practice Address - Fax:414-425-2901
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5707-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist