Provider Demographics
NPI:1417359977
Name:POLYAKOV, VLADIMIR (DDS)
Entity Type:Individual
Prefix:DR
First Name:VLADIMIR
Middle Name:
Last Name:POLYAKOV
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 1:19231 VICTORY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-6318
Mailing Address - Country:US
Mailing Address - Phone:818-345-5432
Mailing Address - Fax:
Practice Address - Street 1:19231 VICTORY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-6318
Practice Address - Country:US
Practice Address - Phone:818-345-5432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-16
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374801223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery