Provider Demographics
NPI:1386135879
Name:PUVALOWSKI, ALISA (RDH)
Entity type:Individual
Prefix:MISS
First Name:ALISA
Middle Name:
Last Name:PUVALOWSKI
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 480430
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48048-0430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:58144 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:MI
Practice Address - Zip Code:48048
Practice Address - Country:US
Practice Address - Phone:586-749-8002
Practice Address - Fax:586-749-5381
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist