Provider Demographics
NPI:1790171007
Name:POLACEK, JENNA NICOLE (DDS)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:NICOLE
Last Name:POLACEK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 S EOLA RD STE D
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60503-6485
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:708-216-5560
Practice Address - Street 1:2211 S EOLA RD STE D
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60503-6485
Practice Address - Country:US
Practice Address - Phone:630-851-5250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190306161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice