Provider Demographics
NPI:1437702917
Name:PUTNAM DENTAL WELLNESS PLLC
Entity Type:Organization
Organization Name:PUTNAM DENTAL WELLNESS PLLC
Other - Org Name:KOALA DENTAL WELLNESS NY-1
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:F
Authorized Official - Last Name:ERN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:845-363-0400
Mailing Address - Street 1:11825 STATE ROUTE 40
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-8842
Mailing Address - Country:US
Mailing Address - Phone:309-839-9941
Mailing Address - Fax:
Practice Address - Street 1:2435 ROUTE 6 STE 5
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-2538
Practice Address - Country:US
Practice Address - Phone:845-363-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-23
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty