Provider Demographics
NPI:1831674274
Name:POLIVKA, JENNI K (RDH)
Entity Type:Individual
Prefix:
First Name:JENNI
Middle Name:K
Last Name:POLIVKA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 S PUBLIC RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-7093
Mailing Address - Country:US
Mailing Address - Phone:303-665-3036
Mailing Address - Fax:303-665-3397
Practice Address - Street 1:1701 W 72ND AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80221-2721
Practice Address - Country:US
Practice Address - Phone:303-650-4460
Practice Address - Fax:720-565-4128
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.002025246124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist