Provider Demographics
NPI:1952468464
Name:CUNNINGHAM, CHARLES FREDERICK (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:FREDERICK
Last Name:CUNNINGHAM
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 1:202 S ELDORADO RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-4471
Mailing Address - Country:US
Mailing Address - Phone:309-663-6551
Mailing Address - Fax:309-663-2578
Practice Address - Street 1:202 S ELDORADO RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4471
Practice Address - Country:US
Practice Address - Phone:309-663-6551
Practice Address - Fax:309-663-2578
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist