Provider Demographics
NPI:1164585519
Name:MULLASSERIL, PAUL MATHEWS (DDS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:MATHEWS
Last Name:MULLASSERIL
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 26901
Mailing Address - Street 2:DCS 209
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73190-0001
Mailing Address - Country:US
Mailing Address - Phone:405-271-5714
Mailing Address - Fax:405-271-2405
Practice Address - Street 1:1201 N STONEWALL AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1214
Practice Address - Country:US
Practice Address - Phone:405-271-5714
Practice Address - Fax:405-271-2405
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK53601223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics