Provider Demographics
NPI:1225114952
Name:MARTELLO, CHARLES PATRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PATRICK
Last Name:MARTELLO
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 1:340 WEST LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423
Mailing Address - Country:US
Mailing Address - Phone:815-464-6500
Mailing Address - Fax:815-464-6503
Practice Address - Street 1:340 WEST LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423
Practice Address - Country:US
Practice Address - Phone:815-464-6500
Practice Address - Fax:815-464-6503
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19020124122300000X
IL370002701223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery