Provider Demographics
NPI:1508842410
Name:PATTERSON, CHARLES WALTER (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WALTER
Last Name:PATTERSON
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 1:515 CHAMBERLAIN LN UNIT 209
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-9289
Mailing Address - Country:US
Mailing Address - Phone:630-210-5419
Mailing Address - Fax:
Practice Address - Street 1:2876 N PINAL AVE STE 4
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-7944
Practice Address - Country:US
Practice Address - Phone:520-374-2225
Practice Address - Fax:520-374-2229
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0105891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD010589OtherDENTAL LICENSE