Provider Demographics
NPI:1588944987
Name:POLLIWOG DENTAL LLC
Entity type:Organization
Organization Name:POLLIWOG DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:TARVER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:863-899-1617
Mailing Address - Street 1:255 SE 17TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471
Mailing Address - Country:US
Mailing Address - Phone:352-274-9731
Mailing Address - Fax:352-274-9731
Practice Address - Street 1:255 SE 17TH ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471
Practice Address - Country:US
Practice Address - Phone:352-274-9731
Practice Address - Fax:352-274-9731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-17
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN186701223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty