Healthcare Provider Details

I. General information

NPI: 1720529019
Provider Name (Legal Business Name): WALDEMAR DAUDT POLIDO DDS, MS, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: WALDEMAR D. POLIDO DDS, MS, PHD

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 W MICHIGAN ST
INDIANAPOLIS IN
46202-5211
US

IV. Provider business mailing address

1121 W MICHIGAN ST
INDIANAPOLIS IN
46202-5211
US

V. Phone/Fax

Practice location:
  • Phone: 317-278-3632
  • Fax:
Mailing address:
  • Phone: 317-278-4456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number98001085A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: