Healthcare Provider Details

I. General information

NPI: 1679077978
Provider Name (Legal Business Name): CHARLES BYRON THORNTON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 03/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 COLLEGE AVE BLDG 286
ALTON IL
62002-4742
US

IV. Provider business mailing address

2800 COLLEGE AVE BLDG 286
ALTON IL
62002-4742
US

V. Phone/Fax

Practice location:
  • Phone: 618-474-7119
  • Fax:
Mailing address:
  • Phone: 618-474-7119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021.001637
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: