Healthcare Provider Details

I. General information

NPI: 1326088170
Provider Name (Legal Business Name): CHARLES P. SUKURS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHUCK SUKURS D.D.S.

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11479 LANTERN RD
FISHERS IN
46038-2947
US

IV. Provider business mailing address

11479 LANTERN RD
FISHERS IN
46038-2947
US

V. Phone/Fax

Practice location:
  • Phone: 317-841-1996
  • Fax: 317-841-2819
Mailing address:
  • Phone: 317-841-1996
  • Fax: 317-841-2819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12007903
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: