Healthcare Provider Details

I. General information

NPI: 1043607872
Provider Name (Legal Business Name): ALISSA NICOLE PULLOS D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E 1ST ST STE 103
HINSDALE IL
60521
US

IV. Provider business mailing address

105 E 1ST ST STE 103
HINSDALE IL
60521-4248
US

V. Phone/Fax

Practice location:
  • Phone: 630-789-8070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019032322
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: