Provider Demographics
NPI:1114001302
Name:POLITO, NICHOLAS S (DDS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:S
Last Name:POLITO
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 1:1109 WEST PARK AVE.
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2552
Mailing Address - Country:US
Mailing Address - Phone:847-367-1133
Mailing Address - Fax:847-367-3388
Practice Address - Street 1:1109 WEST PARK AVE.
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2552
Practice Address - Country:US
Practice Address - Phone:847-367-1133
Practice Address - Fax:847-367-3388
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice