Provider Demographics
NPI:1487902615
Name:POLSE, ALAN MERLIN (DDS)
Entity type:Individual
Prefix:DR
First Name:ALAN
Middle Name:MERLIN
Last Name:POLSE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 LARKIN AVE SUITE 102
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123
Mailing Address - Country:US
Mailing Address - Phone:847-888-8108
Mailing Address - Fax:847-888-8170
Practice Address - Street 1:2000 LARKIN AVE SUITE 102
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123
Practice Address - Country:US
Practice Address - Phone:847-888-8108
Practice Address - Fax:847-888-8170
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-20
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1915649122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist