Provider Demographics
NPI:1972569317
Name:PUERINI, KAJA (DMD)
Entity type:Individual
Prefix:
First Name:KAJA
Middle Name:
Last Name:PUERINI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KAJA
Other - Middle Name:
Other - Last Name:STYCZYNSKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 312
Mailing Address - Street 2:WELLONE PRIMARY MEDICAL AND DENTAL CARE
Mailing Address - City:PASCOAG
Mailing Address - State:RI
Mailing Address - Zip Code:02859-0312
Mailing Address - Country:US
Mailing Address - Phone:401-567-0800
Mailing Address - Fax:401-567-0900
Practice Address - Street 1:36 BRIDGE WAY
Practice Address - Street 2:WELLONE PRIMARY MEDICAL AND DENTAL CARE
Practice Address - City:PASCOAG
Practice Address - State:RI
Practice Address - Zip Code:02859-3131
Practice Address - Country:US
Practice Address - Phone:401-567-0800
Practice Address - Fax:401-568-0582
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN02891122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIKP58677Medicaid