Provider Demographics
NPI:1710002712
Name:POLISUK, STEVEN MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:MICHAEL
Last Name:POLISUK
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 1:24459 GODDARD RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-3933
Mailing Address - Country:US
Mailing Address - Phone:734-946-8620
Mailing Address - Fax:734-946-6272
Practice Address - Street 1:24459 GODDARD RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3933
Practice Address - Country:US
Practice Address - Phone:734-946-8620
Practice Address - Fax:734-946-6272
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010138761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice