Provider Demographics
NPI:1033701495
Name:PSP HEALTH
Entity Type:Organization
Organization Name:PSP HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:S
Authorized Official - Last Name:PAMULA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MD
Authorized Official - Phone:262-634-4646
Mailing Address - Street 1:1925 S GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4654
Mailing Address - Country:US
Mailing Address - Phone:262-634-4646
Mailing Address - Fax:262-634-4694
Practice Address - Street 1:1925 S GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4654
Practice Address - Country:US
Practice Address - Phone:262-634-4646
Practice Address - Fax:262-634-4694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty