Provider Demographics
NPI:1679977458
Name:PUMILIA FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:PUMILIA FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:PACITA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PUMILIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, DIPLOMATE ABDSM
Authorized Official - Phone:815-398-2410
Mailing Address - Street 1:755 S MULFORD RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-4208
Mailing Address - Country:US
Mailing Address - Phone:815-398-2410
Mailing Address - Fax:815-398-2620
Practice Address - Street 1:755 S MULFORD RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-4208
Practice Address - Country:US
Practice Address - Phone:815-398-2410
Practice Address - Fax:815-398-2620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL319.010939122300000X
IL019021788332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No122300000XDental ProvidersDentistGroup - Single Specialty