Provider Demographics
NPI:1902011208
Name:MULLALLY, PATRICK JOSEPH (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:JOSEPH
Last Name:MULLALLY
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 GENEVA LANE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441
Mailing Address - Country:US
Mailing Address - Phone:231-780-2716
Mailing Address - Fax:
Practice Address - Street 1:513 SEMINOLE RD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-3719
Practice Address - Country:US
Practice Address - Phone:231-733-9676
Practice Address - Fax:231-733-0868
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019169122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist