Provider Demographics
NPI:1437341336
Name:POLK, DIANA SUZANNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:SUZANNE
Last Name:POLK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 N BEVERWYCK RD
Mailing Address - Street 2:
Mailing Address - City:LAKE HIAWATHA
Mailing Address - State:NJ
Mailing Address - Zip Code:07034-2518
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 N BEVERWYCK RD
Practice Address - Street 2:
Practice Address - City:LAKE HIAWATHA
Practice Address - State:NJ
Practice Address - Zip Code:07034-2518
Practice Address - Country:US
Practice Address - Phone:973-334-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI018791001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice