Provider Demographics
NPI:1114033438
Name:POLING, HARVEY DENNIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:HARVEY
Middle Name:DENNIS
Last Name:POLING
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 1:1458 SUNDANCER LN
Mailing Address - Street 2:
Mailing Address - City:KEWAUNEE
Mailing Address - State:WI
Mailing Address - Zip Code:54216-1917
Mailing Address - Country:US
Mailing Address - Phone:920-388-3005
Mailing Address - Fax:
Practice Address - Street 1:430 MAIN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-5115
Practice Address - Country:US
Practice Address - Phone:920-431-0345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5320-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33765300Medicaid
NE4044OtherDENTAL LICENSE