MEDICARE: DR. GUS PULOS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	120008816	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	351688238	OTHER	IN	TAX ID #

General Provider Information

NPI Number	:	1184743890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GUS PULOS DDS

Provider Business Mailing Address
First Line	:	1002 N MITTHOEFFER RD
Second Line	:	SUITE B
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46229-2461
Country	:	US
Telephone Number	:	317-898-6666
Fax Number	:	317-898-4965

Provider Business Practice Location Address
First Line	:	1002 N MITTHOEFFER RD
Second Line	:	SUITE B
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46229-2461
Country	:	US
Telephone Number	:	317-898-6666
Fax Number	:	317-898-4965

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	10/18/2012

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