Provider Demographics
NPI:1962012690
Name:POLACK, MEGHAN CLAIRE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MEGHAN
Middle Name:CLAIRE
Last Name:POLACK
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 1:347 HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-3117
Mailing Address - Country:US
Mailing Address - Phone:313-300-1362
Mailing Address - Fax:
Practice Address - Street 1:24901 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-1367
Practice Address - Country:US
Practice Address - Phone:586-772-2090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2021-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901600681122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5315221004OtherSTATE OF MICHIGAN
MI2901600681OtherSTATE OF MICHIGAN