Healthcare Provider Details

I. General information

NPI: 1770409211
Provider Name (Legal Business Name): AUDREY POLK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 W VAN BUREN ST UNIT 4208
CHICAGO IL
60607-3945
US

IV. Provider business mailing address

235 W VAN BUREN ST UNIT 4208
CHICAGO IL
60607-3945
US

V. Phone/Fax

Practice location:
  • Phone: 480-415-8488
  • Fax:
Mailing address:
  • Phone: 480-415-8488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.037278
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: