Provider Demographics
NPI:1588854665
Name:POLAN, BENJAMIN L
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:L
Last Name:POLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BENJAMIN
Other - Middle Name:L
Other - Last Name:POLAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:100 CUMMINGS CTR STE 104M
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-6105
Mailing Address - Country:US
Mailing Address - Phone:978-922-1824
Mailing Address - Fax:978-524-0992
Practice Address - Street 1:100 CUMMINGS CTR STE 104M
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6105
Practice Address - Country:US
Practice Address - Phone:978-922-1824
Practice Address - Fax:978-524-0992
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA14772122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist