Provider Demographics
NPI:1396360137
Name:POLACEK, JOSHUA M
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:M
Last Name:POLACEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 MOUNT ROYAL BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENSHAW
Mailing Address - State:PA
Mailing Address - Zip Code:15116-2207
Mailing Address - Country:US
Mailing Address - Phone:412-486-5155
Mailing Address - Fax:412-487-3525
Practice Address - Street 1:35 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:CLARION
Practice Address - State:PA
Practice Address - Zip Code:16214-1934
Practice Address - Country:US
Practice Address - Phone:814-226-8690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0427091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice