Provider Demographics
NPI:1902053135
Name:POLK, BRIEN R (DDS)
Entity Type:Individual
Prefix:
First Name:BRIEN
Middle Name:R
Last Name:POLK
Suffix:
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 1:731 N SAMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-3961
Mailing Address - Country:US
Mailing Address - Phone:731-589-3621
Mailing Address - Fax:
Practice Address - Street 1:95 US HIGHWAY 51 BYP W
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-1935
Practice Address - Country:US
Practice Address - Phone:731-286-1271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8909122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist