Healthcare Provider Details

I. General information

NPI: 1649214164
Provider Name (Legal Business Name): ANDREW ROBERT MULLENDORE D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 E BROAD ST
COLUMBUS OH
43213-1509
US

IV. Provider business mailing address

6555 E BROAD ST
COLUMBUS OH
43213-1509
US

V. Phone/Fax

Practice location:
  • Phone: 614-427-0400
  • Fax:
Mailing address:
  • Phone: 614-427-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2004012411
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number30-023253
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number096558
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: