Healthcare Provider Details

I. General information

NPI: 1437702917
Provider Name (Legal Business Name): PUTNAM DENTAL WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 ROUTE 6 STE 5
BREWSTER NY
10509-2538
US

IV. Provider business mailing address

11825 STATE ROUTE 40
DUNLAP IL
61525-8842
US

V. Phone/Fax

Practice location:
  • Phone: 845-363-0400
  • Fax:
Mailing address:
  • Phone: 309-839-9941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: CARL F ERN
Title or Position: OWNER
Credential: DDS
Phone: 845-363-0400