Provider Demographics
NPI:1619594868
Name:PULSIPHER, NATHAN JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:JOHN
Last Name:PULSIPHER
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 1:1300 N OAKLAND AVE STE B
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3008
Mailing Address - Country:US
Mailing Address - Phone:417-326-6061
Mailing Address - Fax:
Practice Address - Street 1:1300 N OAKLAND AVE STE B
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-3008
Practice Address - Country:US
Practice Address - Phone:417-326-6061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKT-73461223G0001X
MO2021026772122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice