Healthcare Provider Details

I. General information

NPI: 1063613511
Provider Name (Legal Business Name): LEE PULLEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 WOOD ST
WATER VALLEY MS
38965-2602
US

IV. Provider business mailing address

117 WOOD ST
WATER VALLEY MS
38965-2602
US

V. Phone/Fax

Practice location:
  • Phone: 662-473-2296
  • Fax:
Mailing address:
  • Phone: 662-473-2296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateMS

VIII. Authorized Official

Name: DR. LEE PULLEN
Title or Position: DENTIST OWNER
Credential: D.M.D
Phone: 662-473-2296