Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | #7111 | TN |
NPI | 1073635843 |
---|---|
Provider Name | Dr. Larry Sean Mullins |
First Address | Bristol, TN 37620-0213 |
Second Address | Bristol, TN 37620-0213 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2007 |
Last Update Date | 08/07/2007 |