MEDICARE: DR. ANDREW ROBERT MULLENDORE D.D.S., M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	2004012411	MO
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	30-023253	OH
3	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	096558	OH

General Provider Information

NPI Number	:	1649214164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANDREW ROBERT MULLENDORE D.D.S., M.D.

Provider Business Mailing Address
First Line	:	6555 E BROAD ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43213-1509
Country	:	US
Telephone Number	:	614-427-0400
Fax Number	:

Provider Business Practice Location Address
First Line	:	6555 E BROAD ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43213-1509
Country	:	US
Telephone Number	:	614-427-0400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	12/13/2016

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