Healthcare Provider Details

I. General information

NPI: 1093181380
Provider Name (Legal Business Name): VIMI MUTALIK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2015
Last Update Date: 08/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W 12TH AVE ROOM 2195
COLUMBUS OH
43210-1267
US

IV. Provider business mailing address

305 W 12TH AVE ROOM 2195
COLUMBUS OH
43210-1267
US

V. Phone/Fax

Practice location:
  • Phone: 614-247-4282
  • Fax:
Mailing address:
  • Phone: 614-247-4282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberRES3634
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: