Provider Demographics
NPI:1669821831
Name:POLENA, KOSTIKA (DMD)
Entity Type:Individual
Prefix:
First Name:KOSTIKA
Middle Name:
Last Name:POLENA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 S TONOPAH DR
Mailing Address - Street 2:STE. 200
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4043
Mailing Address - Country:US
Mailing Address - Phone:702-291-2031
Mailing Address - Fax:702-366-1483
Practice Address - Street 1:8430 FARM RD
Practice Address - Street 2:STE. 120
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131-8166
Practice Address - Country:US
Practice Address - Phone:702-732-1010
Practice Address - Fax:702-658-6832
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV67701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice