Healthcare Provider Details

I. General information

NPI: 1891735759
Provider Name (Legal Business Name): CHARLES POLAND II DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7526 E 82ND ST SUITE 125
INDIANAPOLIS IN
46256-1461
US

IV. Provider business mailing address

5625 CASTLE CREEK PKY N. DR. SUITE 125
INDIANAPOLIS IN
46250-4304
US

V. Phone/Fax

Practice location:
  • Phone: 317-849-2606
  • Fax: 317-579-8769
Mailing address:
  • Phone: 317-849-2606
  • Fax: 317-585-0006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12006522
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: