Provider Demographics
NPI:1902958275
Name:MOLLARD, DENNIS W (DDS)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:W
Last Name:MOLLARD
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 1:508 W. LAKE STREET
Mailing Address - Street 2:P.O. BOX 387
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48764-0387
Mailing Address - Country:US
Mailing Address - Phone:989-362-6159
Mailing Address - Fax:989-362-6798
Practice Address - Street 1:508 W LAKE ST
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-5106
Practice Address - Country:US
Practice Address - Phone:989-362-6159
Practice Address - Fax:989-362-6798
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI104581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice