Provider Demographics
NPI:1578695086
Name:MAGNUSON, CHARLES WESLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WESLEY
Last Name:MAGNUSON
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 1:1331 CHIMES BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-3549
Mailing Address - Country:US
Mailing Address - Phone:574-232-2047
Mailing Address - Fax:574-232-3252
Practice Address - Street 1:1331 CHIMES BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-3549
Practice Address - Country:US
Practice Address - Phone:574-232-2047
Practice Address - Fax:574-232-3252
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ81141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice