Provider Demographics
NPI:1629558507
Name:PUCEL, DEVON (DDS)
Entity type:Individual
Prefix:DR
First Name:DEVON
Middle Name:
Last Name:PUCEL
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 1:4391 CANAL AVE SW STE A
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2680
Mailing Address - Country:US
Mailing Address - Phone:616-266-0264
Mailing Address - Fax:
Practice Address - Street 1:4391 CANAL AVE SW STE A
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2680
Practice Address - Country:US
Practice Address - Phone:616-266-0264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190113361223G0001X
CODEN.002037541223G0001X
MI29016020001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice