Provider Demographics
NPI:1770571655
Name:POLLACK, MARK STEPHEN (DDS, PC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEPHEN
Last Name:POLLACK
Suffix:
Gender:M
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 VALLEY ST
Mailing Address - Street 2:P.O. BOX 17
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2517
Mailing Address - Country:US
Mailing Address - Phone:860-456-4135
Mailing Address - Fax:860-456-1665
Practice Address - Street 1:122 VALLEY ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2517
Practice Address - Country:US
Practice Address - Phone:860-456-4135
Practice Address - Fax:860-456-1665
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0048201223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics