Provider Demographics
NPI:1225787708
Name:31 ELMGROVE DENTAL LLC
Entity Type:Organization
Organization Name:31 ELMGROVE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:A
Authorized Official - Last Name:POLAK
Authorized Official - Suffix:
Authorized Official - Credentials:CDA
Authorized Official - Phone:401-421-9350
Mailing Address - Street 1:31 ELMGROVE AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31 ELMGROVE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4103
Practice Address - Country:US
Practice Address - Phone:401-421-9350
Practice Address - Fax:401-421-6450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMP01974Medicaid