Provider Demographics
NPI:1346310919
Name:FANKHAUSER, CHARLES EUGENE (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EUGENE
Last Name:FANKHAUSER
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 1:108 22ND AVE SW
Mailing Address - Street 2:SUITE 12
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-2871
Mailing Address - Country:US
Mailing Address - Phone:360-943-5639
Mailing Address - Fax:360-753-3525
Practice Address - Street 1:108 22ND AVE SW
Practice Address - Street 2:SUITE 12
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-2871
Practice Address - Country:US
Practice Address - Phone:360-943-5639
Practice Address - Fax:360-753-3525
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA51211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice