Healthcare Provider Details

I. General information

NPI: 1104747179
Provider Name (Legal Business Name): MASON MULLANEY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 24TH ST
FORT LEE VA
23801-1716
US

IV. Provider business mailing address

1806 BURGUNDY DR
FALLSTON MD
21047-2112
US

V. Phone/Fax

Practice location:
  • Phone: 443-504-3467
  • Fax:
Mailing address:
  • Phone: 443-504-3467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401419956
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: