Provider Demographics
NPI:1376231324
Name:BULGER, MITCHEL
Entity Type:Individual
Prefix:
First Name:MITCHEL
Middle Name:
Last Name:BULGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 N 35TH ST APT 20
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2426
Mailing Address - Country:US
Mailing Address - Phone:810-706-0679
Mailing Address - Fax:
Practice Address - Street 1:4102 CLEAR CREEK RD STE 102
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-5954
Practice Address - Country:US
Practice Address - Phone:810-706-0679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39522122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist