Provider Demographics
NPI:1861246993
Name:IVY PRUITT DMD PLLC
Entity type:Organization
Organization Name:IVY PRUITT DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER, ENDODONTIST
Authorized Official - Prefix:MS
Authorized Official - First Name:IVY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-850-5032
Mailing Address - Street 1:98 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609
Mailing Address - Country:US
Mailing Address - Phone:617-850-5032
Mailing Address - Fax:
Practice Address - Street 1:303 MAIN ST
Practice Address - Street 2:SUITE 1A, FIRST FLOOR
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608
Practice Address - Country:US
Practice Address - Phone:617-850-5032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty