Provider Demographics
NPI:1053352039
Name:PULTMAN, MARK FREDERICK (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:FREDERICK
Last Name:PULTMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:FREDERICK
Other - Last Name:PULTMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12758 BOENKER LN
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2436
Mailing Address - Country:US
Mailing Address - Phone:314-739-3300
Mailing Address - Fax:314-739-0005
Practice Address - Street 1:12758 BOENKER LN
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2436
Practice Address - Country:US
Practice Address - Phone:314-739-3300
Practice Address - Fax:314-739-0005
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice