Healthcare Provider Details

I. General information

NPI: 1699590174
Provider Name (Legal Business Name): MAHADEEP VIRK DMD, MSD & ELLEN POLSKY DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22530 SE 64TH PL STE 130
ISSAQUAH WA
98027-5353
US

IV. Provider business mailing address

PO BOX 460
PUYALLUP WA
98371-0047
US

V. Phone/Fax

Practice location:
  • Phone: 253-848-4000
  • Fax: 253-604-4130
Mailing address:
  • Phone: 253-848-4000
  • Fax: 253-604-4130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ANGIE METZGER
Title or Position: BILLING MANAGER
Credential:
Phone: 253-219-5730