Healthcare Provider Details

I. General information

NPI: 1811173628
Provider Name (Legal Business Name): JUSTIN DANCEL POLANCO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2008
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 S MELROSE DR
VISTA CA
92081-6627
US

IV. Provider business mailing address

44925 BOUCHAINE ST
TEMECULA CA
92592-5577
US

V. Phone/Fax

Practice location:
  • Phone: 951-795-5052
  • Fax:
Mailing address:
  • Phone: 951-795-5052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number53726
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: