Provider Demographics
NPI:1033697396
Name:PUDDU, ELIZABETH (DMD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:PUDDU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1239 MAHANTONGO ST
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3303
Mailing Address - Country:US
Mailing Address - Phone:570-573-8198
Mailing Address - Fax:
Practice Address - Street 1:1932 W MARKET ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-2004
Practice Address - Country:US
Practice Address - Phone:570-622-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041892122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist