Provider Demographics
NPI:1316031859
Name:POLSON, PRESTON H (DDS)
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:H
Last Name:POLSON
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 1:3740 DACORO LN STE 115
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80109-2510
Mailing Address - Country:US
Mailing Address - Phone:303-660-5576
Mailing Address - Fax:
Practice Address - Street 1:3740 DACORO LN STE 115
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80109-2510
Practice Address - Country:US
Practice Address - Phone:303-660-5576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD34561223G0001X
CODEN.00010353122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6D964OtherBLUE CROSS OF IDAHO
ID806115500Medicaid
ID000010028786OtherBLUE SHIELD OF IDAHO
1362826OtherUNITED CONCORDIA