Provider Demographics
NPI:1003030982
Name:MITSCH, JOHN D (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:MITSCH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02188-2337
Mailing Address - Country:US
Mailing Address - Phone:781-335-1576
Mailing Address - Fax:781-335-8401
Practice Address - Street 1:130 BROAD ST
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02188-2337
Practice Address - Country:US
Practice Address - Phone:781-335-1576
Practice Address - Fax:781-335-8401
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11473122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA821971OtherUNITED CONCORDIA
MA0110OtherDELTA DENTAL
MAX11032OtherBLUE CROSS BLUE SHIELD