Basic Information
| Provider Information | |||||||||
| NPI: | 1326220609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLITO | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 799006 | ||||||||
| Address2: | RICHARD J. DONOVAN CORRECTIONAL FACILITY | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921799006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196616500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 480 ALTA RD | ||||||||
| Address2: | RICHARD J. DONOVAN CORRECTIONAL FACILITY | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921790001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196616500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2007 | ||||||||
| LastUpdateDate: | 12/04/2007 | ||||||||
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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 | 122300000X | 32382 | CA | Y | Dental Providers | Dentist |
No ID Information.