Provider Demographics
NPI:1396847828
Name:KALLSTROM, CHARLES CLARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:CLARK
Last Name:KALLSTROM
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 1:302 RANDALL RD
Mailing Address - Street 2:SUITE # 105
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4209
Mailing Address - Country:US
Mailing Address - Phone:630-232-7385
Mailing Address - Fax:630-232-7389
Practice Address - Street 1:302 RANDALL RD
Practice Address - Street 2:SUITE # 105
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4209
Practice Address - Country:US
Practice Address - Phone:630-232-7385
Practice Address - Fax:630-232-7389
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190140851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice