=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912217043
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSAN C. CHARLES, D.D.S., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2010
-----------------------------------------------------
Last Update Date | 10/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2233 GREEN BAY RD
-----------------------------------------------------
City | NORTH CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60064-3006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-689-2900
-----------------------------------------------------
Fax | 847-689-9388
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2233 GREEN BAY RD
-----------------------------------------------------
City | NORTH CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60064-3006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-689-2900
-----------------------------------------------------
Fax | 847-689-9388
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SUSAN CHRISTINE CHARLES
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 847-689-2900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019.028167
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------