Provider Demographics
NPI:1871794057
Name:ROE, CHARLES WILSON X (DDS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILSON
Last Name:ROE
Suffix:X
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 1:314 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:PINCKNEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62274-1336
Mailing Address - Country:US
Mailing Address - Phone:618-357-2445
Mailing Address - Fax:618-357-9549
Practice Address - Street 1:314 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:PINCKNEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62274-1336
Practice Address - Country:US
Practice Address - Phone:618-357-2445
Practice Address - Fax:618-357-9549
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19014396122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist