Provider Demographics
NPI:1760466080
Name:MULLEN, THOMAS R (DMD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:MULLEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8466 HERRING RUN RD
Mailing Address - Street 2:STE D
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973
Mailing Address - Country:US
Mailing Address - Phone:302-629-3588
Mailing Address - Fax:302-629-0274
Practice Address - Street 1:8466 HERRING RUN RD
Practice Address - Street 2:STE D
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973
Practice Address - Country:US
Practice Address - Phone:302-629-3588
Practice Address - Fax:302-629-0274
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG10008851223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000081302Medicaid
DE118500Medicare ID - Type Unspecified
DE0000081302Medicaid