Healthcare Provider Details

I. General information

NPI: 1265545461
Provider Name (Legal Business Name): CHARLES RANDALL HUTTON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E ADAMS ST
WINAMAC IN
46996-1567
US

IV. Provider business mailing address

201 E ADAMS ST
WINAMAC IN
46996-1567
US

V. Phone/Fax

Practice location:
  • Phone: 574-946-6747
  • Fax: 574-946-4323
Mailing address:
  • Phone: 574-946-6747
  • Fax: 574-946-4323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12007612A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: