MEDICARE: DR. ALLYSON BURGESS MULDER D.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	1223G0001X	General Practice Dentistry	2901020749	MI

General Provider Information

NPI Number	:	1881958411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALLYSON BURGESS MULDER D.M.D

Provider Business Mailing Address
First Line	:	2005 LEONARD ST NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-3827
Country	:	US
Telephone Number	:	616-453-5331
Fax Number	:	616-453-9235

Provider Business Practice Location Address
First Line	:	2005 LEONARD ST NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-3827
Country	:	US
Telephone Number	:	616-453-5331
Fax Number	:	616-453-9235

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

Provider Enumeration Date	:	06/28/2012
Last Update Date	:	07/01/2015

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