Basic Information
| Provider Information | |||||||||
| NPI: | 1992125488 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCMULLAN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 824 HEWITT DRIVE SUITE 300 | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2544204211 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1801 CAMINO DE SALUD | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059254031 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2014 | ||||||||
| LastUpdateDate: | 08/17/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 30638 | TX | Y | Dental Providers | Dentist | 390200000X | #TD-00-64 | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.