Provider Demographics
NPI:1871073478
Name:MULLINS, TRISTA
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:MULLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRISTA
Other - Middle Name:
Other - Last Name:WYMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:338 E MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:GRANVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43023-1415
Mailing Address - Country:US
Mailing Address - Phone:812-267-6311
Mailing Address - Fax:
Practice Address - Street 1:11660 UPPER GILCHRIST RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-9084
Practice Address - Country:US
Practice Address - Phone:740-399-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.031815122300000X
IN12013038A122300000X
OH30.026333122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0423186Medicaid
IN300019367Medicaid