Provider Demographics
NPI:1275762866
Name:POULSEN, RACHEL ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RACHEL
Middle Name:ANN
Last Name:POULSEN
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 1:2006 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-5612
Mailing Address - Country:US
Mailing Address - Phone:574-259-8571
Mailing Address - Fax:
Practice Address - Street 1:2006 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-5612
Practice Address - Country:US
Practice Address - Phone:574-259-8571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-05
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011310A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist