Healthcare Provider Details

I. General information

NPI: 1144353467
Provider Name (Legal Business Name): E CHARLES ECKSTEIN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 10/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 W COLISEUM BLVD
FORT WAYNE IN
46805-1010
US

IV. Provider business mailing address

PO BOX 316
WILLIAMSVILLE NY
14231
US

V. Phone/Fax

Practice location:
  • Phone: 260-969-5367
  • Fax:
Mailing address:
  • Phone: 716-204-4999
  • Fax: 716-623-2963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number02985501
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number9282
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS035365
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number016 0002137
License Number StateVT
# 5
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12010964A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: