Provider Demographics
NPI:1902975303
Name:MULLEN, JACKIE MAURICE (DDSPA)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:MAURICE
Last Name:MULLEN
Suffix:
Gender:M
Credentials:DDSPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 N WINSTEAD AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-8467
Mailing Address - Country:US
Mailing Address - Phone:252-443-7575
Mailing Address - Fax:252-443-0858
Practice Address - Street 1:901 N WINSTEAD AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-8467
Practice Address - Country:US
Practice Address - Phone:252-443-7575
Practice Address - Fax:252-443-0858
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8996276Medicaid
NC8996276Medicaid