Provider Demographics
NPI:1023372968
Name:MULLEN, WESLEY CLARK (DDS)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:CLARK
Last Name:MULLEN
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:PO BOX 1359
Mailing Address - Street 2:
Mailing Address - City:AVA
Mailing Address - State:MO
Mailing Address - Zip Code:65608-1359
Mailing Address - Country:US
Mailing Address - Phone:417-683-4831
Mailing Address - Fax:417-683-1602
Practice Address - Street 1:5520 N FARMER BRANCH RD
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-5315
Practice Address - Country:US
Practice Address - Phone:417-582-7030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013013394122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist