MEDICARE: DR. CHARLES WESLEY MAGNUSON 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	IN8114	IN

General Provider Information

NPI Number	:	1578695086
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES WESLEY MAGNUSON D.D.S.

Provider Business Mailing Address
First Line	:	1331 CHIMES BLVD
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46615-3549
Country	:	US
Telephone Number	:	574-232-2047
Fax Number	:	574-232-3252

Provider Business Practice Location Address
First Line	:	1331 CHIMES BLVD
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46615-3549
Country	:	US
Telephone Number	:	574-232-2047
Fax Number	:	574-232-3252

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

Provider Enumeration Date	:	03/10/2007
Last Update Date	:	07/08/2007

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