Provider Demographics
NPI:1619183076
Name:BECKWELL, CHARLES PATRICK JR (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:PATRICK
Last Name:BECKWELL
Suffix:JR
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 1:22301 GREATER MACK AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2376
Mailing Address - Country:US
Mailing Address - Phone:586-777-6440
Mailing Address - Fax:586-777-3195
Practice Address - Street 1:22301 GREATER MACK AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2376
Practice Address - Country:US
Practice Address - Phone:586-777-6440
Practice Address - Fax:586-777-3195
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010148571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice