1134143241 NPI number — DR. JERROLD JEROME POLLACK DDS RPH

Table of content: DR. JERROLD JEROME POLLACK DDS RPH (NPI 1134143241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134143241 NPI number — DR. JERROLD JEROME POLLACK DDS RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLLACK
Provider First Name:
JERROLD
Provider Middle Name:
JEROME
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS RPH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134143241
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5405 WOODLYN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERICK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21703-6963
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-371-7730
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 REISTERSTOWN RD
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21208-1416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-659-7828
Provider Business Practice Location Address Fax Number:
410-653-7303
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  6505 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1223X0400X , with the licence number: 3810 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)





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