Provider Demographics
NPI:1609515436
Name:MULLINS, TYLER RYAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:RYAN
Last Name:MULLINS
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 1:37290 OLD PERKINS RD
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3764
Mailing Address - Country:US
Mailing Address - Phone:225-677-9999
Mailing Address - Fax:
Practice Address - Street 1:37290 OLD PERKINS RD
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-3764
Practice Address - Country:US
Practice Address - Phone:225-677-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7324122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA68721Medicaid