1922366475 NPI number — MULLASSERIL PC

Table of content: (NPI 1922366475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922366475 NPI number — MULLASSERIL PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MULLASSERIL PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHAWNEE ORTHODONTICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922366475
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
504 SHAWNEE MALL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHAWNEE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74804-1317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-878-8899
Provider Business Mailing Address Fax Number:
405-878-8896

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
504 SHAWNEE MALL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHAWNEE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74804-1317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-878-8899
Provider Business Practice Location Address Fax Number:
405-878-8896
Provider Enumeration Date:
05/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MULLASSERIL
Authorized Official First Name:
ANAITA
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
405-878-8899

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  172 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200432170A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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