Healthcare Provider Details

I. General information

NPI: 1083773303
Provider Name (Legal Business Name): CHARLES FOULKE HINE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 AUTUMN BREEZE CT
INDIANAPOLIS IN
46237-9412
US

IV. Provider business mailing address

5701 AUTUMN BREEZE CT
INDIANAPOLIS IN
46237-9412
US

V. Phone/Fax

Practice location:
  • Phone: 317-213-8478
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12010356A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: