Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D13468 | MN |
N | 1223D0001X | Dental Public Health | D13468 | MN |
NPI | 1649687674 |
---|---|
Provider Name | Dr. Jeffrey Polzin |
First Address | Duluth, MN 55805-2402 |
Second Address | Duluth, MN 55805-2402 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/07/2014 |
Last Update Date | 22/07/2014 |