Provider Demographics
NPI:1588634471
Name:WITKOWSKI, CHARLES EDWARD SR (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EDWARD
Last Name:WITKOWSKI
Suffix:SR
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:PO BOX 5549
Mailing Address - Street 2:SUITE 109
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602
Mailing Address - Country:US
Mailing Address - Phone:423-283-4555
Mailing Address - Fax:423-283-3044
Practice Address - Street 1:1021 W OAKLAND AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2191
Practice Address - Country:US
Practice Address - Phone:423-283-4555
Practice Address - Fax:423-283-3044
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0044261223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3225406Medicare ID - Type Unspecified
TNT74435Medicare UPIN