Provider Demographics
NPI:1932174356
Name:ELWELL, CHARLES WILLIAM JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:ELWELL
Suffix:JR
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 1:7 CLIFFORD DR
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-1250
Mailing Address - Country:US
Mailing Address - Phone:850-651-6882
Mailing Address - Fax:850-651-6692
Practice Address - Street 1:7 CLIFFORD DR
Practice Address - Street 2:
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-1250
Practice Address - Country:US
Practice Address - Phone:850-651-6882
Practice Address - Fax:850-651-6692
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00125901223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU60737Medicare UPIN
FLK3890Medicare ID - Type UnspecifiedGROUP #
FL64712BMedicare ID - Type Unspecified