Provider Demographics
NPI:1720529019
Name:POLIDO, WALDEMAR (DDS)
Entity Type:Individual
Prefix:
First Name:WALDEMAR
Middle Name:
Last Name:POLIDO
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 1:479 CHIMNEY ROCK DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-1500
Mailing Address - Country:US
Mailing Address - Phone:317-278-4456
Mailing Address - Fax:
Practice Address - Street 1:1121 W MICHIGAN ST
Practice Address - Street 2:DS307B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5211
Practice Address - Country:US
Practice Address - Phone:317-278-3632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INLDF1700081223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery