Provider Demographics
NPI:1699808857
Name:POLVERINI, PETER J (DDS, DMSC)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:POLVERINI
Suffix:
Gender:M
Credentials:DDS, DMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1509
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:1011 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-1078
Practice Address - Country:US
Practice Address - Phone:734-763-6933
Practice Address - Fax:734-763-5142
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901016040122300000X, 207ZP0102X, 1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
No122300000XDental ProvidersDentist
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4504373Medicaid
MI4070694Medicaid
MI195816845OtherBCBS OF MI MED SURGICAL
OH2667583Medicaid
MI4874042Medicaid
MID160400OtherBCBS OF MI DENTAL
MID160400OtherBCBS OF MI DENTAL
MI4504373Medicaid
MI0N65440005Medicare PIN