Healthcare Provider Details

I. General information

NPI: 1992125488
Provider Name (Legal Business Name): DAVID MCMULLAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 CAMINO DE SALUD
ALBUQUERQUE NM
87102
US

IV. Provider business mailing address

824 HEWITT DRIVE SUITE 300
WACO TX
76712
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-4031
  • Fax:
Mailing address:
  • Phone: 254-420-4211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30638
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number#TD-00-64
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: