MEDICARE: DR. BRIAN A MULDER D.D.S.

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	5315022676	MI

General Provider Information

NPI Number	:	1700930161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN A MULDER D.D.S.

Provider Business Mailing Address
First Line	:	2008 EASTCASTLE DR SE STE C
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-8874
Country	:	US
Telephone Number	:	616-455-8400
Fax Number	:

Provider Business Practice Location Address
First Line	:	2008 EASTCASTLE SE
Second Line	:	SUITE C
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508
Country	:	US
Telephone Number	:	616-455-8400
Fax Number	:	616-455-4283

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

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	05/22/2020

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