Provider Demographics
NPI:1881958411
Name:MULDER, ALLYSON BURGESS (DMD)
Entity type:Individual
Prefix:DR
First Name:ALLYSON
Middle Name:BURGESS
Last Name:MULDER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 LEONARD ST NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-3827
Mailing Address - Country:US
Mailing Address - Phone:616-453-5331
Mailing Address - Fax:616-453-9235
Practice Address - Street 1:2005 LEONARD ST NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-3827
Practice Address - Country:US
Practice Address - Phone:616-453-5331
Practice Address - Fax:616-453-9235
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010207491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice