=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578715686
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MULLEN AND ASSOCIATES, DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2008
-----------------------------------------------------
Last Update Date | 10/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 PINECROFT DRIVE
-----------------------------------------------------
City | CLAYTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-585-7321
-----------------------------------------------------
Fax | 919-585-7323
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 PINECROFT DRIVE
-----------------------------------------------------
City | CLAYTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-585-7321
-----------------------------------------------------
Fax | 919-585-7323
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JASON WAYNE MULLEN
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 919-585-7321
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 8174
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------