Healthcare Provider Details

I. General information

NPI: 1033131487
Provider Name (Legal Business Name): JASON L POLK D. M. D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SCARBROUGH ST SUITE B
RICHLAND MS
39218-9770
US

IV. Provider business mailing address

PO BOX 180607
RICHLAND MS
39218-0607
US

V. Phone/Fax

Practice location:
  • Phone: 601-932-0606
  • Fax: 601-932-0703
Mailing address:
  • Phone: 601-932-0606
  • Fax: 601-932-0703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3137
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: