Provider Demographics
NPI:1851389597
Name:POWELL, CHRISTOPHER THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:THOMAS
Last Name:POWELL
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 1:31 BRIARCLIFF PROF CTR
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1775
Mailing Address - Country:US
Mailing Address - Phone:815-933-0990
Mailing Address - Fax:815-933-1274
Practice Address - Street 1:31 BRIARCLIFF PROF CTR
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1775
Practice Address - Country:US
Practice Address - Phone:815-933-0990
Practice Address - Fax:815-933-1274
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU20430Medicare UPIN
IL369370Medicare ID - Type Unspecified