Provider Demographics
NPI:1023144540
Name:POLIS, SUSAN JEANNE (DDS)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:JEANNE
Last Name:POLIS
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 1:549 GRUBSTAKE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7640
Mailing Address - Country:US
Mailing Address - Phone:907-235-1286
Mailing Address - Fax:907-235-1263
Practice Address - Street 1:549 GRUBSTAKE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7640
Practice Address - Country:US
Practice Address - Phone:907-235-1286
Practice Address - Fax:907-235-1263
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK9351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKD951Medicaid