Provider Demographics
NPI:1679077978
Name:THORNTON, CHARLES BYRON (DMD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:BYRON
Last Name:THORNTON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 COLLEGE AVE BLDG 286
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4742
Mailing Address - Country:US
Mailing Address - Phone:618-474-7119
Mailing Address - Fax:
Practice Address - Street 1:2800 COLLEGE AVE BLDG 286
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4742
Practice Address - Country:US
Practice Address - Phone:618-474-7119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0016371223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics