Provider Demographics
NPI:1073961157
Name:MULLIGAN, MIRANDA JOY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:JOY
Last Name:MULLIGAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 FULLER ST. S.
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379
Mailing Address - Country:US
Mailing Address - Phone:952-445-6657
Mailing Address - Fax:952-445-0674
Practice Address - Street 1:250 FULLER ST. S.
Practice Address - Street 2:SUITE 250
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379
Practice Address - Country:US
Practice Address - Phone:952-445-6657
Practice Address - Fax:952-445-0674
Is Sole Proprietor?:No
Enumeration Date:2016-05-30
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13672122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist