MEDICARE: DR. RYAN MICHAEL MULLIGAN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	2019021896	MO
2	1223G0001X	General Practice Dentistry	2019021896	MO

General Provider Information

NPI Number	:	1275193229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RYAN MICHAEL MULLIGAN DDS

Provider Business Mailing Address
First Line	:	7040 WATERMAN AVE
Second Line	:
City	:	UNIVERSITY CITY
State	:	MO
Zip	:	63130-4323
Country	:	US
Telephone Number	:	314-359-1682
Fax Number	:

Provider Business Practice Location Address
First Line	:	4527 FOREST PARK AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-2113
Country	:	US
Telephone Number	:	314-367-7200
Fax Number	:	314-367-0508

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2019
Last Update Date	:	08/23/2021

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