MEDICARE: CHARLES EUGENE FANKHAUSER D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5121	WA

General Provider Information

NPI Number	:	1346310919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES EUGENE FANKHAUSER D.D.S.

Provider Business Mailing Address
First Line	:	108 22ND AVE SW
Second Line	:	SUITE 12
City	:	OLYMPIA
State	:	WA
Zip	:	98501-2871
Country	:	US
Telephone Number	:	360-943-5639
Fax Number	:	360-753-3525

Provider Business Practice Location Address
First Line	:	108 22ND AVE SW
Second Line	:	SUITE 12
City	:	OLYMPIA
State	:	WA
Zip	:	98501-2871
Country	:	US
Telephone Number	:	360-943-5639
Fax Number	:	360-753-3525

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	07/08/2007

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