Provider Demographics
NPI:1134118581
Name:POLANCO, ANA LIVIA (DDS)
Entity Type:Individual
Prefix:
First Name:ANA
Middle Name:LIVIA
Last Name:POLANCO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-3450
Mailing Address - Country:US
Mailing Address - Phone:718-456-0751
Mailing Address - Fax:718-418-2407
Practice Address - Street 1:1640 MADISON ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-3450
Practice Address - Country:US
Practice Address - Phone:718-456-0751
Practice Address - Fax:718-418-2407
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047001-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice