Healthcare Provider Details

I. General information

NPI: 1588634471
Provider Name (Legal Business Name): CHARLES EDWARD WITKOWSKI SR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 W OAKLAND AVE SUITE 109
JOHNSON CITY TN
37604-2191
US

IV. Provider business mailing address

PO BOX 5549 SUITE 109
JOHNSON CITY TN
37602
US

V. Phone/Fax

Practice location:
  • Phone: 423-283-4555
  • Fax: 423-283-3044
Mailing address:
  • Phone: 423-283-4555
  • Fax: 423-283-3044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS004426
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: