Healthcare Provider Details

I. General information

NPI: 1528474962
Provider Name (Legal Business Name): BRYAN MULLEN D.M.D., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 475 BOX 1993
FPO AP
96350-9998
US

IV. Provider business mailing address

25 FERNLAKES DR
BLUFFTON SC
29910-6417
US

V. Phone/Fax

Practice location:
  • Phone: 46-816-8808
  • Fax:
Mailing address:
  • Phone: 843-384-8414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number8415
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8415
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: