Provider Demographics
NPI:1881608974
Name:LULLOFF, ANDREW R (DDS)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:R
Last Name:LULLOFF
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 1:2353 S RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5069
Mailing Address - Country:US
Mailing Address - Phone:920-499-0471
Mailing Address - Fax:920-499-8312
Practice Address - Street 1:2353 S RIDGE RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5069
Practice Address - Country:US
Practice Address - Phone:920-499-0471
Practice Address - Fax:920-499-8312
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5143-0151223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIORTHOMedicare UPIN