Provider Demographics
NPI:1437234887
Name:MOLLOY, MICHAEL JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:MOLLOY
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 1:4620 OLD BROADWAY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-1759
Mailing Address - Country:US
Mailing Address - Phone:865-688-2045
Mailing Address - Fax:
Practice Address - Street 1:4620 OLD BROADWAY ST
Practice Address - Street 2:SUITE A
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-1759
Practice Address - Country:US
Practice Address - Phone:865-688-2045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN48121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice