Provider Demographics
NPI:1497177042
Name:POLILLO, BRIAN (DDS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:POLILLO
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 1:16810 MERIDIAN E
Mailing Address - Street 2:SUITE J107
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-9604
Mailing Address - Country:US
Mailing Address - Phone:253-848-7777
Mailing Address - Fax:253-848-7783
Practice Address - Street 1:16810 MERIDIAN E
Practice Address - Street 2:SUITE J107
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-9604
Practice Address - Country:US
Practice Address - Phone:253-848-7777
Practice Address - Fax:253-848-7783
Is Sole Proprietor?:No
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60439325122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist