Healthcare Provider Details

I. General information

NPI: 1417399171
Provider Name (Legal Business Name): ANDREW STEVEN MULLET DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 09/05/2021
Certification Date: 09/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLANTATION ISLAND DR S STE 104B
ST AUGUSTINE FL
32080-3110
US

IV. Provider business mailing address

1301 PLANTATION ISLAND DR S STE 104B
ST AUGUSTINE FL
32080-3110
US

V. Phone/Fax

Practice location:
  • Phone: 904-461-5566
  • Fax: 904-461-0084
Mailing address:
  • Phone: 904-461-5566
  • Fax: 904-461-0084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN24472
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: