Provider Demographics
NPI:1255665634
Name:MULL, JUSTIN C (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:C
Last Name:MULL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 MAIN STREET DENTAL ASSOCIATES
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02081-1729
Mailing Address - Country:US
Mailing Address - Phone:508-668-8008
Mailing Address - Fax:508-668-8808
Practice Address - Street 1:1428 MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081-1729
Practice Address - Country:US
Practice Address - Phone:508-668-8008
Practice Address - Fax:508-668-8808
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18560151223S0112X
CA513631223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty