Provider Demographics
NPI:1467581611
Name:POLK, CHARLES EDWIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EDWIN
Last Name:POLK
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 1:1518 W 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4372
Mailing Address - Country:US
Mailing Address - Phone:405-372-1300
Mailing Address - Fax:405-372-0037
Practice Address - Street 1:1518 W 8TH AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4372
Practice Address - Country:US
Practice Address - Phone:405-372-1300
Practice Address - Fax:405-372-0037
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK34461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics