Basic Information
| Provider Information | |||||||||
| NPI: | 1528603503 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELLEN POLSKY DDS AND BOBBY VIRK DMD, PS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9317 113TH ST E STE A | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983733876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538487000 | ||||||||
| FaxNumber: | 2534466138 | ||||||||
| Practice Location | |||||||||
| Address1: | 34704 11TH PL S STE 101 | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980038730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539465322 | ||||||||
| FaxNumber: | 2534466138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2019 | ||||||||
| LastUpdateDate: | 11/13/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | YORK | ||||||||
| AuthorizedOfficialFirstName: | XENIA | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2538487000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.