Provider Demographics
NPI:1952617664
Name:MIDDLETON FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:MIDDLETON FAMILY DENTISTRY LLC
Other - Org Name:CHARLES H MIDDLETON DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:H
Authorized Official - Last Name:MIDDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-484-3136
Mailing Address - Street 1:1234 E DUPONT RD STE 4
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-484-3136
Mailing Address - Fax:
Practice Address - Street 1:1234 E DUPONT RD STE 4
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1545
Practice Address - Country:US
Practice Address - Phone:260-484-3136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008119122300000X
IN12011467A122300000X
IN12007605122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty