Provider Demographics
NPI:1437278470
Name:SHOWALTER, CHARLES RUSSELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RUSSELL
Last Name:SHOWALTER
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 1:300 S WEST ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-5021
Mailing Address - Country:US
Mailing Address - Phone:630-665-0650
Mailing Address - Fax:630-665-0687
Practice Address - Street 1:300 S WEST ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-5021
Practice Address - Country:US
Practice Address - Phone:630-665-0650
Practice Address - Fax:630-665-0687
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice