Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 21498 | CA |
NPI | 1104957224 |
---|---|
Provider Name | Dr. Dennis M. Polacek |
First Address | Fresno, CA 93711-7118 |
Second Address | Fresno, CA 93711-7118 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/03/2007 |
Last Update Date | 08/07/2007 |