Provider Demographics
NPI:1902823420
Name:KNEEDLER, CHARLES FORREST (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:FORREST
Last Name:KNEEDLER
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 1:3600 N ILL
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226
Mailing Address - Country:US
Mailing Address - Phone:618-234-3700
Mailing Address - Fax:618-234-4076
Practice Address - Street 1:3600 N ILL
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226
Practice Address - Country:US
Practice Address - Phone:618-234-3700
Practice Address - Fax:618-234-4076
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1913055122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist