Provider Demographics
NPI:1639394000
Name:MULL, ROBERT GERALD JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GERALD
Last Name:MULL
Suffix:JR
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 1:1698 BRISTOL RIDGE DR . NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544
Mailing Address - Country:US
Mailing Address - Phone:616-453-7471
Mailing Address - Fax:
Practice Address - Street 1:3935 LAKE MICHIGAN DR NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534-7844
Practice Address - Country:US
Practice Address - Phone:616-453-7755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI17685122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist