Provider Demographics
NPI:1639501091
Name:CHISWELL, CHARLES LAWRENCE (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LAWRENCE
Last Name:CHISWELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 BEECHMONT RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-2835
Mailing Address - Country:US
Mailing Address - Phone:859-608-4118
Mailing Address - Fax:859-608-4118
Practice Address - Street 1:613 BEECHMONT RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-2835
Practice Address - Country:US
Practice Address - Phone:859-608-4118
Practice Address - Fax:859-608-4118
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4570122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist