Provider Demographics
NPI:1780707869
Name:POLISE, ERIC A
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:A
Last Name:POLISE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 ELM STREET
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456
Mailing Address - Country:US
Mailing Address - Phone:315-781-2002
Mailing Address - Fax:315-781-2422
Practice Address - Street 1:30 ELM STREET
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456
Practice Address - Country:US
Practice Address - Phone:315-781-2002
Practice Address - Fax:315-781-2422
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50051566122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02571011Medicaid