MEDICARE: KOSTIKA POLENA D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	6770	NV

General Provider Information

NPI Number	:	1669821831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KOSTIKA POLENA D.M.D.

Provider Business Mailing Address
First Line	:	526 S TONOPAH DR
Second Line	:	STE. 200
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-4043
Country	:	US
Telephone Number	:	702-291-2031
Fax Number	:	702-366-1483

Provider Business Practice Location Address
First Line	:	8430 FARM RD
Second Line	:	STE. 120
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-8166
Country	:	US
Telephone Number	:	702-732-1010
Fax Number	:	702-658-6832

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2016
Last Update Date	:	06/08/2016

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