Provider Demographics
NPI:1003287129
Name:MITCHELL ORAL SURGERY AND IMPLANT CENTERS PA
Entity Type:Organization
Organization Name:MITCHELL ORAL SURGERY AND IMPLANT CENTERS PA
Other - Org Name:MOSAIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:727-842-5180
Mailing Address - Street 1:6731 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-1928
Mailing Address - Country:US
Mailing Address - Phone:727-842-5180
Mailing Address - Fax:
Practice Address - Street 1:2535 LANDMARK DR STE 105
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-3930
Practice Address - Country:US
Practice Address - Phone:727-791-6529
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN108021223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty