Provider Demographics
NPI:1174693865
Name:POLMAN LARSON, PERRI ANN
Entity type:Individual
Prefix:MRS
First Name:PERRI
Middle Name:ANN
Last Name:POLMAN LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PERRI
Other - Middle Name:ANN
Other - Last Name:POLMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:17599 KENWOOD TRAIL W
Mailing Address - Street 2:STE 7
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044
Mailing Address - Country:US
Mailing Address - Phone:952-435-9737
Mailing Address - Fax:952-435-9737
Practice Address - Street 1:17599 KENWOOD TRAIL W
Practice Address - Street 2:STE 7
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044
Practice Address - Country:US
Practice Address - Phone:952-435-9737
Practice Address - Fax:952-435-9737
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10103122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist