Provider Demographics
NPI:1619978319
Name:WETZEL, CHARLES F (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:F
Last Name:WETZEL
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:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:ELCHO
Mailing Address - State:WI
Mailing Address - Zip Code:54428-0339
Mailing Address - Country:US
Mailing Address - Phone:715-275-4484
Mailing Address - Fax:715-275-4533
Practice Address - Street 1:W10610 CLINIC ST
Practice Address - Street 2:
Practice Address - City:ELCHO
Practice Address - State:WI
Practice Address - Zip Code:54428-9619
Practice Address - Country:US
Practice Address - Phone:715-275-4484
Practice Address - Fax:715-275-4533
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001503015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33547100Medicaid