Provider Demographics
NPI:1417085184
Name:DANA W MULLIS DMD PC
Entity Type:Organization
Organization Name:DANA W MULLIS DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO DMD
Authorized Official - Prefix:DR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:W
Authorized Official - Last Name:MULLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-374-1127
Mailing Address - Street 1:PO BOX 4098
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-4098
Mailing Address - Country:US
Mailing Address - Phone:478-374-1127
Mailing Address - Fax:478-374-3588
Practice Address - Street 1:1003 PLAZA AVE
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023
Practice Address - Country:US
Practice Address - Phone:478-374-1127
Practice Address - Fax:478-374-3588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011878122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00803151BMedicaid