Provider Demographics
NPI:1265545461
Name:HUTTON, CHARLES RANDALL (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RANDALL
Last Name:HUTTON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:WINAMAC
Mailing Address - State:IN
Mailing Address - Zip Code:46996-1567
Mailing Address - Country:US
Mailing Address - Phone:574-946-6747
Mailing Address - Fax:574-946-4323
Practice Address - Street 1:201 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:WINAMAC
Practice Address - State:IN
Practice Address - Zip Code:46996-1567
Practice Address - Country:US
Practice Address - Phone:574-946-6747
Practice Address - Fax:574-946-4323
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007612A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice