Provider Demographics
NPI:1588853857
Name:POLTORAK, THEODORE JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:JOHN
Last Name:POLTORAK
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 1:77 CENTRAL SQ
Mailing Address - Street 2:
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221-2168
Mailing Address - Country:US
Mailing Address - Phone:609-927-4336
Mailing Address - Fax:609-926-3310
Practice Address - Street 1:77 CENTRAL SQ
Practice Address - Street 2:
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-2168
Practice Address - Country:US
Practice Address - Phone:609-927-4336
Practice Address - Fax:609-926-3310
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ14481122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist