Healthcare Provider Details

I. General information

NPI: 1306157623
Provider Name (Legal Business Name): CHARLENE DRAKOS D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8963 BROADWAY
MERRILLVILLE IN
46410-7039
US

IV. Provider business mailing address

8963 BROADWAY
MERRILLVILLE IN
46410-7039
US

V. Phone/Fax

Practice location:
  • Phone: 219-769-0744
  • Fax: 219-769-0768
Mailing address:
  • Phone: 219-769-0744
  • Fax: 219-769-0768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12008968
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: