Healthcare Provider Details

I. General information

NPI: 1255363156
Provider Name (Legal Business Name): EDWARD S POLZIN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 AIRPORT RD
ONEIDA WI
54155
US

IV. Provider business mailing address

PO BOX 365
ONEIDA WI
54155-0365
US

V. Phone/Fax

Practice location:
  • Phone: 920-869-2711
  • Fax:
Mailing address:
  • Phone: 920-869-2711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5853-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: