Healthcare Provider Details

I. General information

NPI: 1144546805
Provider Name (Legal Business Name): CHARLES ROBERT POLZIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2819 NATIONAL DR
ONALASKA WI
54650-6703
US

IV. Provider business mailing address

2819 NATIONAL DR
ONALASKA WI
54650-6703
US

V. Phone/Fax

Practice location:
  • Phone: 608-782-8193
  • Fax: 608-782-4517
Mailing address:
  • Phone: 608-782-8193
  • Fax: 608-782-4517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6605-15
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number6605-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: