Provider Demographics
NPI:1891126454
Name:POLIVKA, JOHN WILLIAM (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:POLIVKA
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 1:11000 JANN CT
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE HIGHLANDS
Mailing Address - State:IL
Mailing Address - Zip Code:60525-7308
Mailing Address - Country:US
Mailing Address - Phone:708-699-6659
Mailing Address - Fax:
Practice Address - Street 1:11000 JANN CT
Practice Address - Street 2:
Practice Address - City:LA GRANGE HIGHLANDS
Practice Address - State:IL
Practice Address - Zip Code:60525-7308
Practice Address - Country:US
Practice Address - Phone:708-699-6659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.029578122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist