Provider Demographics
NPI:1902943632
Name:MCNULTY, JAMES ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ALAN
Last Name:MCNULTY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4642 OBERLIN AVE
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-3164
Mailing Address - Country:US
Mailing Address - Phone:440-282-2510
Mailing Address - Fax:440-282-2510
Practice Address - Street 1:4642 OBERLIN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3164
Practice Address - Country:US
Practice Address - Phone:440-282-2510
Practice Address - Fax:440-282-2510
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH139401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0210748Medicaid