Provider Demographics
NPI:1669415063
Name:POLUS, PHILIP G (DDS)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:G
Last Name:POLUS
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 1:1549 S COURT ST
Mailing Address - Street 2:STE B
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-4809
Mailing Address - Country:US
Mailing Address - Phone:219-662-0131
Mailing Address - Fax:219-662-3962
Practice Address - Street 1:1549 S COURT ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-4809
Practice Address - Country:US
Practice Address - Phone:219-662-0131
Practice Address - Fax:219-662-3962
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008055A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist