Provider Demographics
NPI:1770703829
Name:MULLINS, ELMER H JR (DMD)
Entity type:Individual
Prefix:DR
First Name:ELMER
Middle Name:H
Last Name:MULLINS
Suffix:JR
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 1:1452 DIEDERICH BLVD
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:KY
Mailing Address - Zip Code:41169
Mailing Address - Country:US
Mailing Address - Phone:606-836-6022
Mailing Address - Fax:606-836-6008
Practice Address - Street 1:1452 DIEDERICH BLVD
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KY
Practice Address - Zip Code:41169
Practice Address - Country:US
Practice Address - Phone:606-836-6022
Practice Address - Fax:606-836-6008
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY3650122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60036506Medicaid
KY45003837OtherEPSDT