Provider Demographics
NPI:1184743890
Name:PULOS, GUS (DDS)
Entity type:Individual
Prefix:DR
First Name:GUS
Middle Name:
Last Name:PULOS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 N MITTHOEFFER RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-2461
Mailing Address - Country:US
Mailing Address - Phone:317-898-6666
Mailing Address - Fax:317-898-4965
Practice Address - Street 1:1002 N MITTHOEFFER RD
Practice Address - Street 2:SUITE B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-2461
Practice Address - Country:US
Practice Address - Phone:317-898-6666
Practice Address - Fax:317-898-4965
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1200088161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN351688238OtherTAX ID #