Healthcare Provider Details

I. General information

NPI: 1700060712
Provider Name (Legal Business Name): DRS. POLACK AND OLANO, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7431 NEW LINTON HALL RD
GAINESVILLE VA
20155
US

IV. Provider business mailing address

7431 NEW LINTON HALL RD
GAINESVILLE VA
20155
US

V. Phone/Fax

Practice location:
  • Phone: 703-753-8753
  • Fax:
Mailing address:
  • Phone: 703-753-8753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0186
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number0556
License Number StateVA

VIII. Authorized Official

Name: DR. MARIANO ANDRES POLACK
Title or Position: SHAREHOLDER
Credential: DDS, MS
Phone: 703-753-8753