Provider Demographics
NPI:1356630552
Name:POLECK, ELIZABETH ANN (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANN
Last Name:POLECK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:LATHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:584 SPRINGVILLE RD
Mailing Address - Street 2:
Mailing Address - City:NEW HOLLAND
Mailing Address - State:PA
Mailing Address - Zip Code:17557-9564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:584 SPRINGVILLE RD
Practice Address - Street 2:
Practice Address - City:NEW HOLLAND
Practice Address - State:PA
Practice Address - Zip Code:17557-9564
Practice Address - Country:US
Practice Address - Phone:717-354-4711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038530122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist