Provider Demographics
NPI:1215024989
Name:CHARLES H MIDDLETON DDS PC
Entity Type:Organization
Organization Name:CHARLES H MIDDLETON DDS PC
Other - Org Name:CHARLES H MIDDLETON & MARY ELLEN ARGUS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:H
Authorized Official - Last Name:MIDDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS PC
Authorized Official - Phone:260-484-3136
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
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
Practice Address - Country:US
Practice Address - Phone:260-484-3136
Practice Address - Fax:260-484-3137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN00055165OtherUNITED CONCORDIA
IN100079660AMedicare ID - Type Unspecified