Provider Demographics
NPI:1902884125
Name:STUCKEN, CHARLES R SR (DDS)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:R
Last Name:STUCKEN
Suffix:SR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8847 IMPERIAL HWY
Mailing Address - Street 2:SUITE C-2
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242
Mailing Address - Country:US
Mailing Address - Phone:562-861-4011
Mailing Address - Fax:562-861-2601
Practice Address - Street 1:8847 IMPERIAL HWY
Practice Address - Street 2:SUITE C-2
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242
Practice Address - Country:US
Practice Address - Phone:562-861-4011
Practice Address - Fax:562-861-2601
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA28992208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB2899201OtherMEDI CAL