Healthcare Provider Details

I. General information

NPI: 1851885511
Provider Name (Legal Business Name): JONATHON M. PULLARA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2018
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 E FOUNTAIN ST
DODGEVILLE WI
53533-1749
US

IV. Provider business mailing address

2901 W BELTLINE HWY STE 120
MADISON WI
53713-4231
US

V. Phone/Fax

Practice location:
  • Phone: 608-935-5550
  • Fax: 608-935-5168
Mailing address:
  • Phone: 608-443-5500
  • Fax: 608-441-2385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.031652
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: