Provider Demographics
NPI:1134565807
Name:MULYADI, AARON R (DMD)
Entity type:Individual
Prefix:DR
First Name:AARON
Middle Name:R
Last Name:MULYADI
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 1:1160 MCKENDREE PARK LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7062
Mailing Address - Country:US
Mailing Address - Phone:404-374-5353
Mailing Address - Fax:
Practice Address - Street 1:699 PONCE DE LEON AVE NE STE 1
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-1800
Practice Address - Country:US
Practice Address - Phone:678-221-4954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856246122300000X
GADN123363122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist