Provider Demographics
NPI:1467549600
Name:GARY R. PULFER DDS, PC
Entity Type:Organization
Organization Name:GARY R. PULFER DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:PULFER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-482-4483
Mailing Address - Street 1:1405 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5831
Mailing Address - Country:US
Mailing Address - Phone:260-482-4483
Mailing Address - Fax:260-471-9889
Practice Address - Street 1:1405 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5831
Practice Address - Country:US
Practice Address - Phone:260-482-4483
Practice Address - Fax:260-471-9889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120069791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200829910AMedicaid