Basic Information
| Provider Information | |||||||||
| NPI: | 1225045594 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLIGAN | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 FEDERAL ST # 200 | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563564924 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 E LEHIGH AVE | ||||||||
| Address2: | OM2 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157073613 | ||||||||
| FaxNumber: | 2157075404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 07/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | DI02271900 | NJ | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223S0112X | DS030297L | PA | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0055824 | 05 | NJ | MEDICAID |