Provider Demographics
NPI:1952658163
Name:TULI, PETRUSHKA
Entity Type:Individual
Prefix:DR
First Name:PETRUSHKA
Middle Name:
Last Name:TULI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13190 E COLOSSAL CAVE RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-8817
Mailing Address - Country:US
Mailing Address - Phone:520-762-3236
Mailing Address - Fax:
Practice Address - Street 1:13190 E COLOSSAL CAVE RD
Practice Address - Street 2:SUITE 150
Practice Address - City:VAIL
Practice Address - State:AZ
Practice Address - Zip Code:85641-8817
Practice Address - Country:US
Practice Address - Phone:520-762-3236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0085411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice