MEDICARE: PULOS FAMILY DENTISTRY, LLC

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	12008816	IN

General Provider Information

NPI Number	:	1972016392
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PULOS FAMILY DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	10715 GEIST RIDGE CT
Second Line	:
City	:	FISHERS
State	:	IN
Zip	:	46040-9479
Country	:	US
Telephone Number	:	317-485-5850
Fax Number	:

Provider Business Practice Location Address
First Line	:	1002 N MITTHOEFFER RD STE B
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46229-2461
Country	:	US
Telephone Number	:	317-898-6666
Fax Number	:	317-898-4965

Authorized Official
Title or Position	:	MEMBER
Name	:	MRS. MONICA K PULOS
Credential	:
Telephone Number	:	317-485-5850

Provider Enumeration Date	:	11/07/2017
Last Update Date	:	11/07/2017

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