Provider Demographics
NPI:1134509664
Name:MULLALLY, MATTHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:MULLALLY
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 1:9840 WESTPOINT DR
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3360
Mailing Address - Country:US
Mailing Address - Phone:810-990-4241
Mailing Address - Fax:317-537-2687
Practice Address - Street 1:9840 WESTPOINT DR
Practice Address - Street 2:SUITE 500
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-3360
Practice Address - Country:US
Practice Address - Phone:810-990-4241
Practice Address - Fax:317-537-2687
Is Sole Proprietor?:No
Enumeration Date:2015-05-29
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012389A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice