Provider Demographics
NPI:1043607872
Name:PULLOS, ALISSA NICOLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALISSA
Middle Name:NICOLE
Last Name:PULLOS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 E 1ST ST STE 103
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-4248
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 E 1ST ST STE 103
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521
Practice Address - Country:US
Practice Address - Phone:630-789-8070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-20
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190323221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty