Healthcare Provider Details

I. General information

NPI: 1801726567
Provider Name (Legal Business Name): NICHOLAS RICH PUSTAM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 S SUNCOAST BLVD
HOMOSASSA FL
34448-2601
US

IV. Provider business mailing address

16929 FALLING WATERS CT
LAND O LAKES FL
34638-5932
US

V. Phone/Fax

Practice location:
  • Phone: 352-503-3113
  • Fax:
Mailing address:
  • Phone: 813-743-1323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: