Provider Demographics
NPI:1104121110
Name:MULLALLY, NATALIE NICOLE (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:NATALIE
Middle Name:NICOLE
Last Name:MULLALLY
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 NW 35TH PL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-2019
Mailing Address - Country:US
Mailing Address - Phone:352-214-9824
Mailing Address - Fax:
Practice Address - Street 1:15148 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-1817
Practice Address - Country:US
Practice Address - Phone:813-960-0106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-22
Last Update Date:2011-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 184141223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics