Provider Demographics
NPI:1396025763
Name:POLIVY DENTAL ENTERPRISES, PC
Entity Type:Organization
Organization Name:POLIVY DENTAL ENTERPRISES, PC
Other - Org Name:SHAFF AND POLIVY DENTAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:POLIVY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-566-6900
Mailing Address - Street 1:25 BOYLSTON ST
Mailing Address - Street 2:SUITE L15
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-1715
Mailing Address - Country:US
Mailing Address - Phone:617-566-6900
Mailing Address - Fax:617-566-0629
Practice Address - Street 1:25 BOYLSTON ST
Practice Address - Street 2:SUITE L15
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-1715
Practice Address - Country:US
Practice Address - Phone:617-566-6900
Practice Address - Fax:617-566-0629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855535122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty