Provider Demographics
NPI:1447396742
Name:POLANCO, SURMILENA (DDS)
Entity type:Individual
Prefix:
First Name:SURMILENA
Middle Name:
Last Name:POLANCO
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 1:183 JEFFERSON ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055
Mailing Address - Country:US
Mailing Address - Phone:973-472-1010
Mailing Address - Fax:973-473-6232
Practice Address - Street 1:183 JEFFERSON ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055
Practice Address - Country:US
Practice Address - Phone:973-472-1010
Practice Address - Fax:973-473-6232
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D102282700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0077933Medicaid