Provider Demographics
NPI:1508811563
Name:MULLAN, MATTHEW P (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:P
Last Name:MULLAN
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 1:16638 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:FRASER
Mailing Address - State:MI
Mailing Address - Zip Code:48026-3713
Mailing Address - Country:US
Mailing Address - Phone:586-294-4750
Mailing Address - Fax:586-294-8731
Practice Address - Street 1:16638 15 MILE RD
Practice Address - Street 2:
Practice Address - City:FRASER
Practice Address - State:MI
Practice Address - Zip Code:48026-3713
Practice Address - Country:US
Practice Address - Phone:586-294-4750
Practice Address - Fax:586-294-8731
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0141811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1952136Medicaid