Provider Demographics
NPI:1518657766
Name:POLENAKOVIK, ANDREW HARI (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:HARI
Last Name:POLENAKOVIK
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 1:226 GREENMOUNT BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45419-3242
Mailing Address - Country:US
Mailing Address - Phone:937-733-3009
Mailing Address - Fax:
Practice Address - Street 1:3286 PENTAGON BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-1789
Practice Address - Country:US
Practice Address - Phone:937-427-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30.027164122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program