Provider Demographics
NPI:1952474868
Name:FAHNCKE, CHARLES ROBERT (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ROBERT
Last Name:FAHNCKE
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6038 WHITE EAGLE W
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-9599
Mailing Address - Country:US
Mailing Address - Phone:419-824-2108
Mailing Address - Fax:
Practice Address - Street 1:3000 ARLINGTON AVE
Practice Address - Street 2:MAIL STOP 1092
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2595
Practice Address - Country:US
Practice Address - Phone:419-383-3776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-91241223P0700X
MI29010168461223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics