Provider Demographics
NPI:1275193229
Name:MULLIGAN, RYAN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:MICHAEL
Last Name:MULLIGAN
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 1:7040 WATERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63130-4323
Mailing Address - Country:US
Mailing Address - Phone:314-359-1682
Mailing Address - Fax:
Practice Address - Street 1:4527 FOREST PARK AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2113
Practice Address - Country:US
Practice Address - Phone:314-367-7200
Practice Address - Fax:314-367-0508
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-20
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019021896122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist