Provider Demographics
NPI:1306961677
Name:FUNKHOUSER, CARL EDWARD (DDS)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:EDWARD
Last Name:FUNKHOUSER
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 1:220 E MAIN ST
Mailing Address - Street 2:PO BOX 575
Mailing Address - City:CARMI
Mailing Address - State:IL
Mailing Address - Zip Code:62821-1842
Mailing Address - Country:US
Mailing Address - Phone:618-382-5341
Mailing Address - Fax:618-382-5342
Practice Address - Street 1:220 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821-1842
Practice Address - Country:US
Practice Address - Phone:618-382-5341
Practice Address - Fax:618-382-5342
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190155431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice