=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437423928
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POLSKY DDS &VIRK DMD MS PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/29/2012
-----------------------------------------------------
Last Update Date | 02/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1002 15TH ST SW SUITE 215
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98001-6502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-736-6600
-----------------------------------------------------
Fax | 253-736-6601
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 696
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98531-0696
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-736-0928
-----------------------------------------------------
Fax | 360-736-0921
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. ELLEN POLSKY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 617-792-3007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------