Provider Demographics
NPI:1740403260
Name:PULTZ, ROBERT B
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:B
Last Name:PULTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23
Mailing Address - Street 2:621 WASHINGTON AVE
Mailing Address - City:NIAGARA
Mailing Address - State:WI
Mailing Address - Zip Code:54151
Mailing Address - Country:US
Mailing Address - Phone:715-251-1486
Mailing Address - Fax:
Practice Address - Street 1:621 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NIAGARA
Practice Address - State:WI
Practice Address - Zip Code:54151
Practice Address - Country:US
Practice Address - Phone:715-251-1486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3804122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33496400Medicaid