Basic Information
| Provider Information | |||||||||
| NPI: | 1023065315 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLANCO | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | EDUARDO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8704 SLEEPY OAK PL | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336141770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8134053939 | ||||||||
| FaxNumber: | 8134053929 | ||||||||
| Practice Location | |||||||||
| Address1: | 7814 N DALE MABRY HWY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336143220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8134053939 | ||||||||
| FaxNumber: | 8134053929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 01/03/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN16816 | FL | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 075853100 | 05 | FL | MEDICAID |