Provider Demographics
NPI:1407829468
Name:PUCHALSKI, JOHN E (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:PUCHALSKI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10001 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80229-2050
Mailing Address - Country:US
Mailing Address - Phone:303-452-2053
Mailing Address - Fax:303-280-9388
Practice Address - Street 1:10001 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-2050
Practice Address - Country:US
Practice Address - Phone:303-452-2053
Practice Address - Fax:303-280-9388
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1042421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02042422Medicaid