Provider Demographics
NPI:1922341734
Name:PREVENTIVE DENTAL SERVICES, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:PREVENTIVE DENTAL SERVICES, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:JEANNE
Authorized Official - Last Name:POLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS , RDH
Authorized Official - Phone:907-235-1286
Mailing Address - Street 1:549 GRUBSTAKE AVE
Mailing Address - Street 2:SUITE #A
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7640
Mailing Address - Country:US
Mailing Address - Phone:907-235-1286
Mailing Address - Fax:907-235-1263
Practice Address - Street 1:549 GRUBSTAKE AVE
Practice Address - Street 2:SUITE #A
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7640
Practice Address - Country:US
Practice Address - Phone:907-235-1286
Practice Address - Fax:907-235-1263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty