Provider Demographics
NPI:1093875882
Name:MYLAN, VIRGIL M (DDS)
Entity Type:Individual
Prefix:DR
First Name:VIRGIL
Middle Name:M
Last Name:MYLAN
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 1:4954 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436-1071
Mailing Address - Country:US
Mailing Address - Phone:952-935-3532
Mailing Address - Fax:
Practice Address - Street 1:4954 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55436-1071
Practice Address - Country:US
Practice Address - Phone:952-935-3532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN82501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice